Slogan of chronic disease follow-up month

1. What are the long and extended prescriptions of chronic diseases?

For details, please refer to the second paragraph on page 9 of Document No.20172 of Wan Wei Medical Reform Office, and the best answer has been given: patients with contracted chronic diseases with stable condition and good compliance can be prescribed treatment drugs by their family doctors for 4-8 weeks at a time. When the contracted residents who are referred by family doctors to specialized or general hospitals return to primary medical and health institutions for treatment, they can extend the use period of drugs prescribed by hospitals, or prescribe necessary non-essential drugs according to their illness and the situation of being transferred out of hospitals, so that the common diseases prescribed by contracted residents in medical and health institutions above the second level can be provided in primary medical and health institutions in principle.

Two, the family doctor contract service "six one" activities and assessment indicators

(1) Organize publicity activities. To give full play to the role of the contracting service team as a "work team, service team and propaganda team", we can use publicity pages, electronic scrolling screens, banners and slogans, town (village) street wall slogans, taxi electronic screens, newspapers, television, WeChat and other forms to widely publicize them in a form that the masses like. , to promote and serve at the same time, to improve the public's awareness of family doctors' contracting services.

(2) Provide on-site service. The contracting team of family doctors should improve the service mode, adopt the wrong time service and appointment service, and provide on-site service for contracted residents focusing on patients with chronic diseases and inpatients at home and abroad during holidays and slack seasons, and take health knowledge promotion, rehabilitation nursing, Chinese medicine service, health knowledge promotion, medication guidance, dietary guidance, health assessment, systematic personalized treatment plan and updating health records as key follow-up intervention activities.

(3) issue a health prescription. Based on electronic health records, family doctors conduct health assessment, carry out health education, analyze health problems and propose personalized health prescriptions for contracted residents. Briefly explain the pathogenic factors, pathogenesis and diagnostic criteria of the disease for the sick people and key people; Put forward the principles of guidance, intervention and treatment of traditional Chinese and western medicine, health care measures and suggestions for further treatment.

(4) Follow-up. According to the characteristics of different contracted people, various modes such as night follow-up, holiday follow-up, telephone follow-up and WeChat follow-up were adopted, and extended prescriptions and long prescriptions were issued to provide basic public health services, disease referral and rehabilitation guidance.

(5) Establish referral channels. Each unit should set up a graded diagnosis and treatment office, with the leader of the family doctor signing team as a member, who will issue outpatient medical records for patients who need referral and instruct the referral office to open a referral form, register and collect outpatient medical records.

(six) to carry out free medical examination. The free health check-up for the poverty-stricken people aged 50-59 who set up a file for the establishment of the card shall be undertaken by the grassroots medical and health institutions and the family doctor signing team. See the annex for the standards and items of health examination. And do a good job in the organic connection with the special treatment of serious diseases of rural poor people in health and poverty alleviation work, and the newly discovered sick poor people will be treated by designated hospitals.

Contents of supervision and inspection

1, Registration Form of "Six Ones" Publicity Campaign for Family Doctors' Signing Service in Wanrong County

2, Wanrong county family doctor contract service "six one" chronic disease follow-up home service registration form

3. Family doctors in Wanrong County signed the service "Six Ones" to issue health prescription registration forms.

4, Wanrong county family doctor contract service "six one" follow-up registration form

5, grading diagnosis and treatment office organization, referral stub, registration form

5, Wanrong County 50-59 years old poor residents survey roster.

6, Wanrong County, 50-59 years old poor residents signed medical roster.

Third, the slogan of family doctor signing service

(optional)

Article 4 of No.2017195 "Getting Through the Last Mile" in Ji Fa, Wan Wei stipulates that the propaganda slogan of family doctors should be written in communities and villages, which can be referred to as follows:

1, the family doctor entered Wanjia and signed a contract to serve you, me and him.

2. Family doctor service to protect your health.

3, doctors are connected, and health is the first line.

4. Sign up for family doctor service, so that you can have your own health care doctor.

5. Responsible doctors go to rural areas and provide health services to families.

6. Family doctor-the health gatekeeper of urban and rural residents

7. Develop good living habits and advocate a healthy and civilized life.

8. See a family doctor first, so as to save money.

9. Let the family have a doctor and let the doctor enter the family.

10, carry out family doctor contract service-let every household have a family doctor and everyone enjoy health care.

1 1. Family doctor-the health gatekeeper of urban and rural residents.

12, caring service, contracted family doctor service.

13, family doctor-let healthy life live healthier, let sick life live more quality, and make it more convenient and dignified for the elderly with mobility difficulties to see a doctor.

14, enjoy your own responsible doctor and actively sign up for family doctor service.

15, public health services are everywhere, ensuring that health benefits every household.

16, health escorts health, and service takes the community to take off.

17, the family doctor entered Wanjia to provide health services for you, me and him.

18, Gong Shu's service concept of health, love, enthusiasm, care and patience creates a warm, comfortable, assured and happy medical atmosphere for residents.

19, resident health manager, sincerely serving everyone.

20, protect health, enjoy preferential treatment, family doctor services into ten thousand.

2 1, public health is people-oriented, caring for health and caring for people.

22. Stay healthy, enjoy preferential treatment, and sign a contract with a family doctor.

23. Go deep into the countryside, go deep into the family, serve the people and live a healthy life.

24. Family doctor-the health manager of residents, sincerely serving everyone.

25, family doctors into thousands of households, healthy life warm tens of thousands.

26. Buying a contract service package for the elderly is the best gift to honor the elders.

27, a healthy life has an appointment, and the real service is unlimited.

28. Public health will create a healthy road by serving attentively and helping with love.

29. It is better to honor your elders and buy a contract service package.

30. Care is everywhere, and health is real.

3 1, sign a contract to serve the family and be a good health gatekeeper.

32. There is an agreement with the doctor, and someone asks about health.

33. Take care of yourself at ordinary times, see a doctor and help you, family doctor and health consultant.

34. Healthy life has an appointment, and sincere service is unlimited.

Fourth, the interpretation of family doctor contract service policy

1. What is the content of family doctor's contract service?

A: The contract service consists of free service and paid service, mainly including basic public health service, basic medical service and appointment referral, personalized health management service, family sickbed service and corresponding service package setting.

2. What phenomena should we pay attention to now?

A: It is strictly forbidden to "re-sign the contract and neglect performance", "emphasize form and neglect service" and "emphasize progress and neglect quality" to ensure the smooth implementation of contract services.

3. What are the key contents and work objectives of the current contract service?

The contracted service target is all residents. At the beginning, the key targets of the contract service are poor households with established cards, poor families with family planning, elderly people over 65 years old, patients with chronic diseases, preschool children, pregnant women, patients with severe mental disorders at home, patients with advanced cancer maintenance treatment, disabled people with inconvenient life, long-term bedridden people and other residents who need contract service. First of all, ensure that all poor people are included in the scope of family doctor contract services, and provide corresponding free contract services. By the end of 20 17, the coverage rate of family doctors' contract service has reached more than 35%, the coverage rate of poor families with established files and family planning has reached more than 95%, and the coverage rate of key populations has reached more than 65% respectively.

4. How do the internal members of the family doctor contract service team divide their work?

A: The contract service takes the form of team service, and the doctors (general practitioners) in township hospitals are the first responsible persons for the contract service. The team consists of general practitioners, specialists, registered nurses, rural doctors, health managers (or psychological counselors) and social volunteers. Specialist is a doctor in a secondary hospital, providing all-round technical support for family doctors' contract service in time, responsible for the clear diagnosis of patients' condition and the formulation of individualized treatment plans, and teaching for general practitioners and health managers; General practitioners are responsible for implementing the treatment plan of specialists, grasping and handling the illness in time, communicating with specialists in time, making appointments for specialist clinics, and guiding the work of health managers; Nurses, health managers, psychological counselors, rural doctors, etc. Assist specialists and general practitioners to communicate with patients, and be responsible for daily follow-up and screening of patients, individualized health education and lifestyle interventions such as diet and exercise.

Five, family doctor contract service questionnaire

Name: Gender: Age: Population Attribute: Tel:

Hello, I'm from xx township (town) health center. Are you xxx (patient name)?

1. Have doctors in hospitals and health centers signed a service agreement with you?

2. What's the matter with you? Do you take medicine every day? Do you know the name and method of taking medicine?

What's the name of your family contract doctor?

Do you have his contact number?

5. Do you know the duties of a family doctor?

6. What services did the family doctor provide for you?

7. How often do family doctors provide health services?

O quarterly o monthly o weekly o by phone.

8. Have doctors from hospitals and health centers come to check your health? How many times have you checked this year? Never checked once, twice or many times.

9. Are you satisfied with the family doctor service?

10. Do you have any comments or suggestions on the contract service?

Intransitive Verb Health Poverty Alleviation Questionnaire

Name: Gender: Age: Population Attribute: Tel:

Hello, I'm from xx township (town) health center. Are you xxx (patient name)?

1. Did the family doctor sign a service agreement with you?

2. What's wrong with you?

What's the name of your family contract doctor? Can you reach him?

4. What services did the family doctor provide for you?

5. How often do family doctors provide health services?

O quarterly o monthly o weekly o by phone.

6. Did the staff of the medical institution come to check your health? How many times have you checked this year? Never checked once, twice or many times.

7. Have you seen a doctor or been hospitalized this year?

O I haven't seen O, seen the clinic, been in hospital.

8. Did the doctor publicize the compensation policies such as basic medical insurance and critical illness insurance to you? Oh, yes, no, I don't know.

9. Do you know the policy of "pay after treatment" and "centralized treatment for serious illness"?

O knows one thing, O knows two things and O knows nothing.

10, are you satisfied with poverty alleviation through health? What are your views and suggestions on health and poverty alleviation?

Seven, the family doctor contract service brief questions

Unit name: Name: Service scope (village name):

1. What is the specific service content of family doctor contract service?

2. What is the process of family doctor's contract service?

3. How many families and people did your team serve? How many households and people have signed up now? Can it reach 35% of the total population in your village?

Do you know the specific duties of the family doctor who signed the agreement? Do you know what the specific duties of the rural cadres who signed the agreement are?

5. Your opinions and suggestions on family doctor contract service:

Eight, health poverty alleviation short answer questions

1. What is "double signing"?

2. Who are the clients of family doctor contract service, health poverty alleviation and double contract service? How many people are there in your town?

Do you know the policy of "pay after treatment" and "centralized treatment for serious illness"? Describe it briefly.

4. What are the health poverty alleviation policies you know now?

5. What are your views and suggestions on health and poverty alleviation?