In order to implement the spirit of the conference on disease prevention in cities and counties, we will do a solid job in the prevention and treatment of chronic diseases such as hypertension, tuberculosis and diabetes. According to the "county chronic disease management work plan" and the actual situation of our town, this plan is formulated:
(A), mission objectives
1. Implement the blood pressure measurement system for community residents over 35 years old; Measure blood pressure and blood sugar at least once a year.
2. For newly discovered patients with hypertension and diabetes, standardized and complete files must be established. The filing rate and standardized management rate are over 95%, and the effective follow-up rate is 85%.
3. The registration rates of hypertension and diabetes should reach 85% and 2% respectively.
4. The reported data of hypertension, diabetes, stroke and tumor are accurate, complete and timely.
(2) Specific measures
1, there is a special person responsible for the prevention and treatment of chronic diseases in the community.
2, found suspicious TB patients immediately transferred to TB prevention and control institutions for further examination, are not allowed to prescribe anti-tuberculosis drugs.
3, the implementation of full supervision and treatment of infectious pulmonary tuberculosis patients. The standardized drug use rate should reach more than 98%. And timely guide patients to do the necessary examination and sputum re-examination on time, and handle or report the side effects in time.
4. For the first time, community residents over 20 years old take part in the blood pressure test of registered population, and residents over 35 years old take part in the blood pressure and blood sugar test at least once a year, and do a good job in regular physical examination of residents (once a year or once every two years).
5. Grasp the number of residents with hypertension and diabetes in the area, have standardized and complete medical records and registration (hypertension registration rate is 5%, diabetes is 2%), and the standardized management and follow-up rate is over 95%. Quarterly, semi-annual and year-end evaluation should meet the requirements of blood pressure control compliance rate, blood sugar control good rate and case effect evaluation.
6, master the basic situation of the elderly over 60 years old (resident population) within the jurisdiction and have a complete roster, health records and other information, to carry out regular physical examination of the elderly, with work records and materials.
7. Supervise and visit key personnel as required, and make records.
8, in accordance with the requirements of chronic disease prevention and control, timely, accurate, complete and standardized statistics of the original data related to chronic disease prevention and control work into statements, and report on time.
9, according to the needs of the prevention and treatment of various chronic diseases, and actively carry out the corresponding prevention and treatment of chronic diseases, health education and health promotion.
In order to establish and improve the chronic disease management system in line with the social development level of our town, implement the intervention measures for chronic diseases of urban and rural residents, reduce the exposure of major health risk factors, effectively prevent and control chronic diseases such as hypertension and diabetes, implement the national basic public health service standards and superior requirements, and combine the reality of our town, this plan is formulated:
I. Management of Residents' Health Records
1, find out the total number of households and population in the area.
2. Establish health records for residents in this area. On the basis of 30% annual filing rate of 20xx, it is required to complete 80% this year and strive to reach 100%.
3, through the file, grasp the situation of children 0~36 months, pregnant women, hypertension, type 2 diabetes, severe mental illness and the elderly over 65 years old, and implement classified guidance and management.
4, according to the requirements of standardized management, properly record, organize, save, report and update all kinds of data.
Second, the health management of the elderly over 65 years old
1, find out the base number of elderly people over 65 years old within the jurisdiction, and all health centers should register, record and keep the base number and report it to the health centers for summary.
2, the elderly over the age of 65 to conduct a health examination every year, and make a good record of 20xx chronic disease management work plan 5 20xx chronic disease management work plan 5.
3, the elderly over 65 years old for a free blood sugar test every year, and make records.
4. Establish health records through household surveys, require the village filing rate to reach over 95%, strive for 100%, and realize standardized management.
Second, the health management of patients with hypertension (* * * the Communist Youth League work plan)
1. Establish a blood pressure measurement system for people over 35 years old, screen and find patients with hypertension in time, and require the blood pressure measurement ratio of people over 35 years old to reach over 95%.
2. Establish a register of hypertensive patients over 35 years old and implement hierarchical management. The filing rate of each village is required to reach over 95%, and strive to reach 100%.
Patients with hypertension over 3.35 years old should have a health check-up and free blood sugar test every year.
4. Follow-up patients with hypertension who have been diagnosed clearly every three months, and timely follow-up special patients according to their condition. Follow-up records and file contents shall be updated in time, and items shall not be missed.
5. Seriously study service standards, master health knowledge such as health guidance and behavior intervention for patients with chronic diseases, and provide reasonable intervention guidance for patients.
6 in accordance with the requirements of standardized management, properly record, organize, save, report and update all kinds of data and information. Five major work plans for chronic disease management in 20xx.
Health management of patients with type 2 diabetes mellitus
1, and find out the base number of patients with type 2 diabetes in the jurisdiction.
2. Establish a register of patients with type 2 diabetes, implement classified management, report and summarize it, and require that the filing rate in villages should reach over 95%, and strive for 100%.
3. Patients with type 2 diabetes receive health examination and free blood sugar test every year.
4. For general patients, follow-up once every three months, and special patients should be followed up in time according to their condition. Follow-up records should be made, and the contents of files should be updated in time without omission.
5, according to the requirements of standardized management, properly record, organize, save, report and update all kinds of data.
Fourth, the health management of patients with severe mental illness
1, find out and master the base number of patients with severe mental illness within the jurisdiction, and register and report for summary.
2, through household surveys, establish health records, require the village filing rate to reach more than 95%, and strive to 100%.
3, for patients with severe mental illness once a year for a health check-up and free blood sugar testing.
4. For general patients, follow-up once every three months, and special patients should be followed up in time according to their condition. Follow-up records should be made, and the contents of files should be updated in time without omission.
5, according to the requirements of standardized management, properly record, organize, save, report and update all kinds of data.
Under the correct leadership of the superior departments, our town has strictly implemented the spirit of the superior documents, fully mobilized the enthusiasm and initiative of the basic public health services in the town, and achieved good results. The prevention and treatment of chronic diseases in basic public health services in our town are summarized as follows:
First, conscientiously implement the guiding ideology of chronic disease prevention and treatment.
In 20xx, our town vigorously carried out the prevention and treatment of chronic diseases with emphasis on hypertension, diabetes and neutral psychosis, fully combined with smoking cessation, alcohol control, diet and psychological intervention, actively carried out health education and publicity, reduced the risk factors of key populations, and effectively controlled the incidence and mortality of chronic diseases within its jurisdiction.
Second, constantly improve the function of prevention and treatment of chronic diseases.
Combined with the spirit of superior documents, the professional ethics level of public health service personnel for chronic diseases will be continuously improved, so as to ensure that medical personnel adhere to the principle of patient-centered and customer satisfaction, and firmly grasp the chronic diseases that residents in the jurisdiction care about. Constantly improve the service content, improve the service mode, strengthen the management system, do our best to provide convenience for the clients, and ensure that the key groups in the jurisdiction can visit in place. Further adhere to the purpose of service, enhance service awareness, improve service quality and establish a new image of civilization.
Third, establish residents' health records.
In order to ensure the smooth progress of residents' health records, a binding service group headed by the dean was set up to increase publicity and raise residents' awareness of actively filing files. Our hospital adopts the way of door-to-door filing and outpatient filing as a supplement to ensure the authenticity of files. By 20xx65438+February 25th, a total of family health will be established for residents in the jurisdiction.
There are 18540 paper files in Kang Archives, accounting for 7 1.05% of the total population of 2609/kloc-0, of which 5296 files are filed in 20xx, accounting for 20.29% of the total population. The number of electronic files completed is 13260, and computer input accounts for 7 1.52% of the number of files.
III. Contents and measures for the prevention and treatment of chronic diseases
1, strengthen the prevention and treatment of chronic diseases.
In order to strengthen the work, improve the quality and promote the standardization of chronic disease prevention and treatment. Yong 'an Town Chronic Disease Leading Group was established. The staff of the prevention and protection group and rural doctors went deep into villages and households to actively publicize the risk factors of chronic diseases and the treatment of patients with chronic diseases. It has formed a fast and interactive information collection network, which has promoted the smooth completion of the annual work objectives and tasks.
2, the completion of the annual work objectives and tasks
① There were 897 patients with hypertension, 3055 people were followed up, 897 people underwent physical examination, the physical examination rate was 100%, 888 people were managed in a standardized way, the standardized management rate was 98%, the patients with hypertension were controlled, and the vacancy rate was%.
② 259 diabetic patients were recorded, 964 were followed up and 256 were examined, with a physical examination rate of 98%, a standardized management rate of 100% and a control rate of%.
③ Patients with severe psychosis were 5 1 person, followed up for 93 times. The physical examination rate of 32 patients was 100%, and the standardized management rate of 22 patients was 43%.
④ There were 20xx elderly people over 65 years old, with physical examination 1.256 people, and the physical examination rate was 6 1.29%.
3. The prevalence of chronic non-communicable diseases is rising, and the medical expenses are increasing year by year, which has become a prominent social problem in China. There is a contradiction between the limited and relatively fixed economic ability of the elderly and their relatively huge medical needs, which require high-quality and economical services.
Preventive health care and health education are the best cost-effective interventions to strengthen the management of chronic diseases and alleviate the problem of "difficult and expensive medical treatment".
4, regularly carry out self-inspection work, timely picket batch leakage.
Regularly carry out self-examination, in strict accordance with the requirements of Xishui County Center for Disease Control and Prevention, conduct daily self-examination on all work of chronic diseases, prevent mistakes in time, and continuously improve the quality of work. At the same time, carefully analyze and actively correct the problems existing in the evaluation.
5, regular publicity and training of chronic disease prevention and control knowledge.
In view of the health status of residents at different stages and hot consultation issues, we made full use of major festivals such as "Hypertension Prevention Day", "Diabetes Day" and "Severe Mental Illness" to publicize, distributed 600 publicity materials and received 670 educational consultations; Regularly hold health talks on the prevention and treatment of chronic diseases, convey knowledge on the prevention and treatment of chronic diseases such as hypertension, diabetes, severe mental illness and the elderly over 65 to the general public, improve the misunderstanding and blind spots of the general public's understanding of chronic diseases such as hypertension and diabetes, and raise residents' awareness of self-care. Two lectures on health education for chronic diseases were held throughout the year, with 28 participants.
Four. Work experience, existing problems and plans. In the future work, we will further explore the new mechanism of scientific and standardized management, further expand the new functions of chronic disease prevention and treatment services, and strive to create a new situation in the prevention and treatment of chronic diseases in view of the weak standardized management, the overall improvement of the level of outpatient medical staff, and the further expansion of publicity and training activities for hypertension, diabetes, severe mental illness and the elderly over 65.