Hypertension, diabetes, tumor, cardiovascular and cerebrovascular diseases, chronic obstructive pulmonary disease
Scoring: daily prevention, finding ways and follow-up management.
Second, the prevention and treatment of chronic diseases:
One liter: improve the healthy lifestyle of residents.
Early morning: early detection and early treatment.
Three falls: reduce morbidity, disability and mortality.
For example: type 2 diabetes
Third, the service content:
(1) screening
Targeted health education should be given to the high-risk group of type 2 diabetes found in the work, and it is suggested that they should test their fasting blood glucose 1 time at least every year, and receive health guidance from medical staff.
(2) Follow-up evaluation
For patients diagnosed with type 2 diabetes, free fasting blood glucose tests are provided four times a year, and at least four face-to-face follow-up visits are conducted.
(1) Measure fasting blood glucose and blood pressure, and evaluate whether there is any critical situation, such as blood glucose ≥ 16.7mmol/L or blood glucose ≤ 3.9 mmol/L; Systolic blood pressure ≥ 180mmHg and/or diastolic blood pressure ≥110mmhg; Change of consciousness or behavior, breath stinks of rotten apple acetone, palpitation, sweating, loss of appetite, nausea, vomiting, excessive drinking, polyuria, abdominal pain, deep breathing and skin flushing; Persistent tachycardia (heart rate exceeding 100 beats/min); When the body temperature exceeds 39 degrees Celsius or there are other sudden abnormalities, such as sudden drop in vision, higher blood sugar during pregnancy and lactation or other incurable diseases, emergency referral must be made 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 there is no need for emergency referral, ask about the symptoms during the last follow-up to this follow-up.
(3) Measure body weight, calculate body mass index (BMI) and check the pulse of dorsal artery of foot.
(4) Ask patients about their diseases and lifestyles, including cardiovascular and cerebrovascular diseases, smoking, drinking, exercise, staple food intake, etc.
(5) Understand the patients' medication.
(3) Classified intervention
(1) Satisfied with blood sugar control (fasting blood sugar value
(2) For the first time, the patients with unsatisfactory fasting blood glucose control (fasting blood glucose value ≥7.0mmol/L) or adverse drug reactions were instructed according to their medication compliance. If necessary, increase the dosage of existing drugs, replace or increase different hypoglycemic agents, and follow up within 2 weeks.
(3) For patients who are dissatisfied with the control of fasting blood glucose for two consecutive times or whose adverse drug reactions are difficult to control, and have new or aggravated complications, it is recommended to refer them to higher-level hospitals, and actively follow up and refer them within 2 weeks.
(4) 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.
(4) Physical examination
For the patients with type 2 diabetes diagnosed, comprehensive physical examination should be conducted 1 time every year, which can be combined with follow-up. The contents include routine physical examinations such as temperature, pulse, respiration, blood pressure, height, weight, waist circumference, skin, superficial lymph nodes, heart, lungs and abdomen, as well as rough measurement and judgment of oral, visual, auditory and motor functions. For details, please refer to the Health Checklist of Urban and Rural Residents' Health Records Management Service Specification.
Service requirements
(a) the health management of patients with type 2 diabetes is the responsibility of doctors and should be combined with outpatient service. For patients who are not followed up according to the requirements of health management, 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) should screen and find patients with type 2 diabetes through community health diagnosis and outpatient service in their respective jurisdictions, and master the epidemic situation of type 2 diabetes among residents in their respective jurisdictions.
(4) Give full play to the characteristics and functions of traditional Chinese medicine in improving clinical symptoms, improving quality of life and preventing complications, and actively apply traditional Chinese medicine to carry out health management services for diabetic patients.
(five) to strengthen publicity, inform the service content, so that more patients are willing to accept the service.
(six) after each service, the relevant information will be recorded in the patient's health file in time.