First, define the service target.
Patients with essential hypertension aged 35 and above in the jurisdiction.
Second, the service content
(1) hypertension screening
1. The blood pressure of the permanent residents aged 35 and above in the jurisdiction shall be measured when they first visit township hospitals, village clinics and community health service centers (stations) every year.
2. For residents whose systolic blood pressure is ≥ 140mmHg for the first time and/or whose diastolic blood pressure is ≥90mmHg, make an appointment for reexamination after excluding the factors that may lead to the increase of blood pressure. If the blood pressure is higher than the normal value three times that day, it can be initially diagnosed as hypertension. When necessary, it is suggested to refer to a higher hospital for diagnosis, and follow up the referral results within 2 weeks, so as to bring the diagnosed patients with essential hypertension into the health management of patients with hypertension. Patients suspected of secondary hypertension should be referred in time.
3. It is suggested that the high-risk population should have their blood pressure measured at least 1 time every six months and receive lifestyle guidance from medical staff.
(2) For patients with essential hypertension, township hospitals, village clinics and community health service centers (stations) provide at least 4 face-to-face follow-up visits every year.
1. Measure blood pressure and evaluate whether there are critical symptoms, such as systolic blood pressure ≥ 180mmHg and/or diastolic blood pressure ≥110mmhg; Consciousness change, severe headache or dizziness, nausea and vomiting, blurred vision, eye pain, palpitation and chest tightness, dyspnea, inability to lie flat, higher than normal blood pressure during pregnancy or lactation, or other incurable diseases, should be referred urgently after treatment. For emergency referral, township hospitals, village clinics and community health service centers (stations) should actively follow up the referral within 2 weeks.
2. If no emergency referral is needed, ask about the symptoms during the last follow-up to this follow-up.
3. Measure weight and heart rate and calculate body mass index (BMI).
4. Ask the patient's symptoms and lifestyle, including cardiovascular and cerebrovascular diseases, diabetes, smoking, drinking, exercise, salt intake, etc.
5. Understand the patient's medication.
6. According to the patients' blood pressure control and symptoms and signs, the patients were evaluated and classified for intervention.
(1) For patients with satisfactory blood pressure control, no adverse drug reactions, no new complications or no aggravation of the original complications, make an appointment for the next follow-up time.
(2) Patients who are dissatisfied with the first blood pressure control, that is, systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥90mmHg, or who have adverse drug reactions, should increase the dosage of existing drugs, replace or add different antihypertensive drugs when necessary, and follow up for 2 weeks.
(3) For patients who are dissatisfied with blood pressure control for two consecutive times or whose adverse drug reactions are difficult to control, and have new complications or aggravated original complications, it is recommended to refer them to a higher hospital, and actively follow up and refer them within 2 weeks.
7. Carry out targeted health education for all patients, work out lifestyle improvement goals with patients, and evaluate the progress at the next follow-up. Tell the patient to see a doctor as soon as anything goes wrong.
(3) Patients with hypertension should have at least 1 time comprehensive health examination every year, which can be combined with follow-up. The contents include blood pressure, weight, fasting blood glucose, general physical examination and general examination of vision, hearing and mobility. Where conditions permit, it is suggested to increase blood potassium concentration, blood sodium concentration, blood routine, urine routine (or microalbuminuria), fecal occult blood, blood lipid, fundus, electrocardiogram and B-ultrasound. It is suggested that elderly patients should be initially screened for cognitive function and emotional state. For details, please refer to the Health Checklist of Urban and Rural Residents' Health Records Management Service Specification.
Third, the service process
(1) Flow chart of hypertension screening (2) Flow chart of follow-up of hypertension patients.
Fourth, the service requirements
(1) Health management of patients with hypertension is the responsibility of doctors and should be combined with outpatient service. For patients who are not followed up according to the management requirements, the medical staff of township hospitals, village clinics and community health service centers (stations) should take the initiative to contact patients to ensure the continuity of management.
(2) Follow-up includes patient appointment, telephone tracing and home visit.
(3) Township hospitals, village clinics and community health service centers (stations) can screen and find patients with hypertension through community health diagnosis and outpatient service in the local area. It is suggested to measure blood pressure1.30 ~1.39mmhg/85 ~ 89mmhg every six months. Conditional areas, after standardized training of personnel, can refer to the "Guidelines for the Prevention and Treatment of Hypertension in China" for health management of hypertensive patients.
(four) the active application of Chinese medicine to carry out health management services for patients with hypertension.
(five) to strengthen publicity, inform the service content, so that more patients and residents are willing to accept the service.
(six) after each service, the relevant information will be recorded in the patient's health file in time.
Verb (abbreviation of verb) evaluation index
(1) Health management rate of hypertensive patients = number of hypertensive patients managed in that year/total number of hypertensive patients in that year × 100%.
Estimation of the total number of hypertension patients in the jurisdiction: the total resident adult population in the jurisdiction × adult hypertension prevalence rate (obtained or selected as the recent hypertension prevalence index of the province (the whole country) through local epidemiological investigation and community health diagnosis).
(2) Standardized management rate of hypertensive patients = number of hypertensive patients managed as required/number of hypertensive patients managed within one year × 100%.
(3) The blood pressure control rate of the management population = the number of people whose blood pressure reached the standard in the latest follow-up/the number of people who have managed hypertension × 100%.
Six, completes the hypertension patient follow-up service record.
If the above answer is satisfactory, please adopt it as a satisfactory answer in time. I wish you a speedy recovery.