Daily management plan of hypertension 1 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, with high disability and mortality, 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 in the community. Community prevention of chronic diseases is the most effective means of chronic disease prevention, and the quality of community prevention of chronic diseases is related to the effect of chronic disease prevention. Our center fully understands the importance of chronic disease prevention and treatment, integrates chronic disease prevention and treatment into the service assessment objectives of basic public health projects, creates a supporting environment, and takes the road of "combining prevention with prevention". According to the requirements of >, the work plan for prevention and treatment of hypertension and chronic diseases is formulated.
I. Work objectives
1. Through the implementation of the national basic public health service hypertension management project, we will take preventive measures against chronic diseases such as hypertension and related risk factors of urban and rural residents, reduce major health risk factors such as smoking and drinking, and effectively prevent and control hypertension.
2. The registration and filing rate of chronic non-communicable diseases such as hypertension is over 98%; The health check-up rate of the main chronic non-communicable diseases of hypertension diagnosed clearly is over 98%; The standardized management rate of major chronic non-communicable diseases such as hypertension diagnosed clearly reached 60%; Above all, the blood pressure control rate of major chronic non-communicable diseases, such as hypertension, has reached more than 40%.
Second, the main measures
Management of patients with hypertension
According to the management service standard of hypertension patients, standardize the management of hypertension patients aged 35 and above in the jurisdiction.
1. Screening methods for patients with hypertension are: the blood pressure of residents aged 35 and above is measured for the first time every year; Blood pressure was measured during the diagnosis and treatment of residents; Measure blood pressure in health examination and screening of high-risk groups; Let patients contact our center actively through publicity and education; Inquiries in the process of establishing residents' health records.
2. Establish health records of patients with hypertension. Establish health records of patients with hypertension, carry out physical examination, consultation, follow-up and health intervention for patients with hypertension as required, and record relevant information and activities in residents' health records for registration, so as to realize standardized management of the records. Strengthen the standardized management of hypertension patient registration in our center, realize the institutionalization of workflow and standardization of registration data, and meet the requirements of hypertension registration norms. In the process of health management of patients with hypertension, we should make good use of health files and constantly enrich and enrich the contents of health files.
3. Management of patients with hypertension. For patients with hypertension diagnosed, face-to-face follow-up should be conducted at least four times a year. Every follow-up should ask about the condition, carry out blood pressure measurement and other inspection and evaluation, and give health guidance such as medication, diet, exercise and psychology.
4. Health examination of patients with hypertension. Patients with hypertension receive free health examination at least once a year, which can be combined with follow-up. The contents include blood pressure, weight, random blood sugar (blood) determination, general physical examination, general examination of vision, hearing and activity, and blood routine.
5. Strengthen health education and health promotion, conduct lectures and publicity on hypertension knowledge on a regular basis, popularize knowledge on prevention and treatment of hypertension among community residents, control various risk factors, and improve people's health awareness.
Daily management work plan for hypertension 2 In order to establish and improve the hypertension management system in line with the economic and social development level of our hospital, implement the intervention measures for hypertension among residents in our hospital, reduce the exposure of major health risk factors, and effectively prevent and control hypertension, this year's work plan is formulated according to the national basic public health service standards and the requirements of Gaolan County Health Bureau on the health management service standards for hypertensive patients, combined with the actual situation of our hospital.
I. Work objectives
(a) the overall goal:
Through the implementation of the basic public health service chronic disease management project, intervention measures were implemented for hypertension and related risk factors of residents in each village, so as to reduce the main health risk factors and effectively prevent and control hypertension.
(2) Annual target:
1, carry out the management of patients with hypertension, with the filing rate of patients with hypertension ≥ 100% and the management rate ≥ 100%.
2. The standardized management rate of hypertension patients is 90%.
Second, the management of patients with hypertension
Early detection, early diagnosis and early treatment of hypertension patients, through standardized management and behavioral intervention, can effectively prevent and control hypertension as soon as possible, thus reducing or delaying the occurrence of hypertension complications and reducing the harm of hypertension.
1, found hypertension patients.
Discovery path:
(1) opportunistic screening
Medical treatment: doctors in town hospitals and village clinics find or diagnose patients with hypertension through blood pressure measurement during diagnosis and treatment.
Blood pressure measuring points: If blood pressure measuring points are set in the medical points of town hospitals and village clinics, the chances of finding them will increase.
(2) Screening of key populations
First visit and blood pressure measurement were conducted for residents aged 35 and above.
Screening high-risk groups, such as overweight and obesity.
(3) Establish the population health file, measure and query the blood pressure when establishing the population health file, and find the patients.
(4) Health check-up refers to patients with hypertension, especially asymptomatic patients with hypertension, who are found in the health check-up of residents or the health check-up organized by the unit.
(5) Through health education or health consultation, patients with hypertension are found.
2. Standardized management of patients with hypertension
The residents' health records should be updated or established in time for the patients with hypertension diagnosed, and managed according to the Guidelines for Prevention and Treatment of Hypertension in China (20xx Basic Edition) and the Health Management Service Standard for Patients with Hypertension. Village doctors should provide at least 4 face-to-face follow-up visits every year, and each follow-up visit should ask about the condition, check and evaluate blood pressure and heart rate measurement, and make follow-up records; Fill in various forms of residents' health records carefully, such as the registration form of follow-up service for hypertensive patients and the two-way referral form. , and do a good job of filing. It is suggested that patients with hypertension should have a physical examination at least once a year, which can be combined with follow-up.
3. Intervention of patients with hypertension
(1) health education: widely publicize the knowledge of hypertension prevention and treatment, improve the self-care awareness of the whole town, and guide the society to pay attention to hypertension prevention and treatment;
(2) Diet intervention: control the intake of sodium salt, fat, tobacco, alcohol, etc. And advocate the use of healthy gadgets, such as oil pan and salt spoon;
(3) Physical activity: Pay attention to the form and amount of exercise and exercise moderately; Take each administrative village as a unit and carry out various forms of activities in combination with the whole * healthy lifestyle action;
(4) Mental factors: mental tension and tension, psychological balance.
Strengthen the self-management of patients with hypertension, and the medical staff in the town provide technical support and guidance for the self-management of patients.
Work plan for daily management of hypertension 3 I. Work objectives
1. Through the implementation of the basic public health service management project for patients with hypertension, we will implement intervention measures for chronic diseases and related risk factors of urban and rural residents, reduce major health risk factors, and effectively prevent and control chronic diseases such as hypertension.
2. Establish health records of patients with hypertension.
Second, the main task
(A), the management of patients with hypertension
1, detecting hypertension
According to the Service Standard of Urban and Rural Residents' Health Records Management, hypertension patients were found by establishing community residents' health records, physical examination, diagnosis and treatment services in our hospital, free blood pressure measurement in the community, active detection and first blood pressure measurement.
2. Registration of patients with hypertension
We will establish a management register of hypertension patients, and input all the information into the relevant database for computerized management.
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, conduct clinical evaluation according to the requirements of hypertension prevention and treatment guidelines, and implement graded management and follow-up. Follow-up takes the form of outpatient follow-up, rural family follow-up and village doctors' help, and adopts drug treatment scheme and non-drug treatment scheme for hypertension patients. When the patient has the situation stipulated in the Service Standard for Urban and Rural Residents' Health Records Management, he will be referred to the superior general hospital in time, and then transferred back to continue 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.
(2) Health guidance and intervention for high-risk groups of hypertension.
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-related knowledge and risk factors through health education, give guidance on healthy lifestyles, and measure blood pressure regularly.
(3) to promote the health of ordinary people in the community.
According to the health needs of the community population, widely publicize the knowledge of hypertension prevention and treatment in the community, advocate a healthy lifestyle, encourage the community population to change bad lifestyles, reduce risk factors, and prevent and reduce the occurrence of hypertension.
1. Establish a publicity window of hypertension prevention and control knowledge in the community, make a leaflet of hypertension prevention and control knowledge, and distribute it to the community people through neighborhood committees and medical stations.
2. Hold lectures and free clinics on hypertension knowledge and healthy lifestyle in the community.
3, the use of community residents' activity rooms and other places where residents are concentrated as propaganda positions for hypertension prevention and treatment knowledge, and put all kinds of publicity materials.
4. Carry out free blood pressure measurement activities in the community.