Self-summary on chronic disease work

Self-summary of chronic disease work

Establish a chronic disease management group to form an effective and feasible work network diagram. Township doctors from each village clinic are the specific staff, and the management group is responsible for business guidance. Next is my self-summary of chronic disease work, I hope it will be helpful to you ~

Self-summary of chronic disease work 1

Chronic diseases in Tianerhe Health Center in 20xx With the strong support of the hospital leaders and the joint efforts of rural doctors in each village clinic, the management work has carried out chronic disease management work in the jurisdiction in accordance with the chronic disease work management regulations, standardized filing and standardized management, etc. Work and achieve certain results.

The chronic disease management work is now summarized as follows:

1. Leaders attach importance to strengthening leadership

Regular meetings of the chronic disease leadership group in the jurisdiction are held regularly to discuss chronic diseases Manage plans and programs, communicate with the person in charge of the clinic, make detailed arrangements for phased work, and win the support of the villagers in the jurisdiction so that the work can be completed smoothly.

2. Network management responsibilities are assigned to people

Full-time chronic disease management personnel are set up to assign responsibilities to people. Chronic disease management groups are established to form an effective and feasible work network diagram. Each village health department Mururoxiang doctors are the specific staff, and the management team is responsible for business guidance.

3. Organize rural doctors’ chronic disease knowledge training to improve rural doctors’ chronic disease service and management knowledge

Regularly organize rural doctors’ chronic disease management knowledge training, and organize Information lectures on the topics of hypertension and diabetes.

4. Strengthen publicity and carry out health consultation

Regularly carry out chronic disease, health education publicity and consultation activities every month. Utilize medical human resources to give full play to their respective strengths, carry out special consultation activities based on each person's characteristics, and measure blood pressure for residents on a voluntary basis. As of December, 11 consultation activities had been organized, with 660 beneficiaries, and more than 3,000 promotional materials distributed, achieving good results.

5. Establish health records and implement systematic management

In accordance with the detailed rules and regulations of chronic disease management, detailed information on hypertension and diabetes service objects has been standardized and established in each village group, and Township doctors are required to conduct regular follow-up visits, and the management team supervises rural doctors on a regular basis. At present, we have established 1546 cases of hypertension, 567 cases of diabetes, and 45 cases of mental illness. The management rate reached 98, the effective management rate was 98, and the standardized management rate was 95.

6. Carry out chronic disease education and monitoring work

Carry out chronic disease monitoring work mainly on hypertension and diabetes, and carry out disease prevention for high-risk groups by distributing promotional materials, lectures, etc. Promote and supervise non-pharmacological and pharmacological treatments.

7. Summary of chronic disease work throughout the year

(1) Hypertension follow-up:

1. There are currently 2,995 patients with hypertension in our town ( *See the roster of patients with hypertension for details). 7,468 people were actually followed up, including 4,116 door-to-door follow-ups, 18 telephone follow-ups, and 3,334 out-patient follow-ups. The follow-up rate in the first half of the year was 79.6. 7452 recycling service coupons.

2. Among the patients who were followed up in the first half of the year, 2,023 had stable blood pressure control and maintained drug treatment; 972 patients had unsatisfactory blood pressure control and had changed drugs.

3. Newly discovered that 1,256 people suffer from hypertension and have been included in chronic disease management.

4. Compared with 20xx in the first half of 20xx, the prevalence of hypertension has declined.

(2) Diabetes follow-up:

1. There are currently 279 diabetic patients in our town (*see the roster of patients with hypertension for details), and 875 people were actually followed up, including 513 door-to-door follow-ups. person times, 2 people were followed up by telephone, and 360 people were followed up at outpatient clinics. The follow-up rate was 93.3. 873 recycling service coupons.

2. Among the patients followed up this quarter, 236 had stable blood sugar control and maintained drug treatment; 43 patients were not satisfied with blood sugar control and had changed drugs.

3. Newly discovered 97 people suffer from diabetes and have been included in chronic disease management.

4. Compared with 20xx in the first half of 20xx, the prevalence of diabetes has declined. Self-summary of chronic disease work 2

In the past 20xx, our chronic disease management team, under the leadership of superiors and with the cooperation of colleagues, has successfully completed relevant tasks. In 20xx, we will continue to work hard and strive to do better and better in the prevention and control of chronic diseases.

1. The progress of chronic disease prevention and control in 20xx

1. Management of hypertension and diabetes

Adhere to the first outpatient diagnosis and testing of residents over 35 years old blood pressure, and include the physical examination of residents and employees into opportunistic screening, to discover and register patients with new chronic diseases and high-risk groups at any time. This year, 741 special files for hypertension and 318 special files for diabetes were created, and the patient registration system was effectively completed. follow-up and annual evaluation.

On the basis of the original two chronic disease groups, one new hypertension and one diabetes self-management group were established. The frequency of group activities continued last year, and the content and format of activities were continuously increased. This year’s *** plan 21 hypertension group activities and 19 diabetes group activities were carried out.

Through lectures, outdoor publicity, free clinics, etc., we carried out publicity activities related to Hypertension and Diabetes Day, including free blood pressure measurements for more than 500 people and blood sugar measurements for more than 350 people; more than 10 types of promotional materials were distributed. About 1,000 copies.

2. Follow-up work for high-risk groups of stroke

This is the second year that our center has carried out stroke follow-up work. This year, our center continues to conduct follow-up work on 322 people with more than 3 risk factors. Four times a year follow-up; 456 people with 1-2 risk factors were followed up once a year; so far, a total of 1,611 people have been followed up, including 4 deaths, 773 lost to follow-up, and 29 referrals.

3. Follow-up work of cancer patients

Through telephone follow-up, neighborhood committee assistance and other methods, the actual number of cancer patients followed was 318, of which 7 were out-of-town patients, 41 were lost to follow-up, and 18 died. people and successfully completed this year’s follow-up work on cancer patients.

4. National Healthy Lifestyle Action

Completed the establishment of our center’s demonstration unit and successfully passed the district and municipal disease control acceptance. In addition, we are actively preparing for the establishment of healthy trails, healthy cabins, and healthy canteens, waiting for acceptance next year.

By cooperating with the training of family health workers, the recruitment and training of 33 healthy lifestyle instructors were completed, and complete guidance, training and activity records were kept.

5. Community diagnosis work

Since the community diagnosis work was officially launched in early June, through cooperation with the streets, collaboration with neighborhood committees, outpatient appointments, online publishing, etc., after 4 months* ** worked together to successfully complete the questionnaire survey and physical examination of 3,010 people in the jurisdiction; the blood test and all data entry work of 2,607 people. Community diagnosis screened 1,346 people who were negative for hepatitis B antigen and antibody, and 979 people were vaccinated with free hepatitis B vaccine; 91 people were positive for hepatitis B antigen, and 45 people were referred to Ditan Hospital for further examination.

7. Aspirin Standardization Action

Conducted a survey on aspirin usage among target groups in general clinics. It lasted 3 weeks, and 1,000 questionnaires were completed and two four-person surveys were conducted. A patient health education activity with content related to chronic diseases, reaching an audience of more than 200 people.

2. Existing problems and main measures

1. Patients with hypertension and diabetes are passively managed, and outpatient doctors should be more proactive.

The current community management of chronic diseases The pattern is that the doctor chases the patient. Patients' attention to the disease is limited to going to the hospital for medical treatment, prescribing medicine, injections, and infusions, and they do not pay attention to lifestyle habits, behaviors, risk factors and other interventions. Therefore, patients with chronic diseases are passively managed, making it difficult to carry out chronic disease work.

In addition to hoping that the government will increase the publicity of chronic diseases and increase residents’ attention to their own health, we also hope that patients with new-onset hypertension and diabetes who visit outpatient clinics, or patients with unsatisfactory blood pressure and blood sugar control , after normal medical consultation and prescription of medicines, our community doctors should take the initiative, take the trouble to speak more, do more health guidance, and advise patients to participate in lectures, large classes, group activities, etc. organized by the hospital.

2. Follow up on high-risk patients with stroke and be practical and realistic

Although our doctors called each and every follow-up visit and took the trouble to explain, but those who came to participate in the follow-up visit However, only half of the patients are at high risk. Most patients refused to participate in the follow-up because there were too few examination items, they had just been examined recently, or for various other reasons. Even among the people who come to participate in the follow-up, only a few people can come on the required date.

For such patients, we will first remind them of the next follow-up time and recommend that they participate in a comprehensive physical examination for the elderly, or at the same time participate in some recently launched free examinations such as community diagnosis. At the same time, for high-risk groups who come to participate in follow-up visits, we will often notify them to attend knowledge lectures on chronic diseases such as stroke, so that residents can feel that the community center cares about them and are willing to accept continuous follow-up visits. However, for those people who did not come to follow-up despite our earnest suggestions, we recorded them realistically and classified them as people who were lost to follow-up.

3. The supportive creation of national healthy lifestyle actions requires long-term financial and material support

The creation of healthy trails and demonstration canteens is difficult to complete by the community center alone. . During this period, it not only requires strong support from the government and streets, but also long-term cooperation from neighborhood committees and relevant departments. As a technical support department, it is undoubtedly a challenge for the community center to independently complete the work of creating a demonstration.

In addition, there are many difficulties in recruiting and training healthy lifestyle instructors to carrying out activities. For this year’s instructor training, our center completed the recruitment and training through cooperation with home care workers. In the process of carrying out activities, more than half of the instructors can perform their duties and do a good job in publicity, but they always forget or fail to provide corresponding information feedback.

4. Community diagnostic work is a project that benefits the people, but sometimes it is not understood.

Community diagnostic work should be regarded as a screening that benefits the people, but sometimes it is not understood. Office: There are too few inspection items, too small gifts, too many questions in the questionnaire...

Residents are scheduled to participate in community diagnosis through different platforms such as streets, neighborhood committees, and the Internet. Different groups of people naturally bring about various problems. In this process, we set up a person to be responsible for on-site arrangements, communication, and coordination; to make appointments for residents by community and time period; different groups of people focus on individualized publicity...

3. Work plan for 20xx

1. Focus on the management of high-risk groups, gather more with less, and accumulate patients

Continue to do a good job in the management of high-risk groups such as hypertension and diabetes, and improve the management of high-risk groups such as stroke and hypertension. Intervention and management of the population; it is not only necessary to publicize knowledge related to chronic disease prevention and control, but also to increase the attention of high-risk groups to their own diseases.

Continue to adhere to the form of chronic disease self-management group activities, gather more with less, and strive to use these benefited group members to drive more patients to join the self-management team and help more and more patients Achieve self-management.

2. Do a good job in stroke follow-up and insist on seeking truth from facts

Keep corresponding follow-up records for high-risk groups who can come for follow-up every time; for those who refuse follow-up due to various reasons, Or those who still cannot be connected after calling three or four times are recorded one by one to indicate that they have been lost to follow-up to ensure the authenticity of the stroke follow-up work.

3. Focus on the National Healthy Lifestyle Action and strengthen community chronic disease intervention

Combined with the National Healthy Lifestyle Action, use demonstration units, healthy huts, and healthy trails to target target groups Health intervention activities focus on unhealthy lifestyles that lead to the occurrence of chronic diseases, and promote salt restriction, tobacco control and physical exercise. Make full use of "No Tobacco Day", "High Blood Pressure Day", "Diabetes Day", "Healthy Lifestyle Day" and other event days to carry out special publicity activities.

4. Strengthen the publicity and education on chronic diseases among corporate white-collar workers and primary and secondary school students

Strengthen communication with enterprises, schools and other units in the jurisdiction, carry out publicity and education activities for workplaces and schools, and effectively use health education and Economic and social benefits of health intervention, strengthen health education and health promotion of chronic disease prevention and treatment among school students.

5. Strengthen knowledge training related to health management

By participating in the center’s weekly business studies and daily intra-department studies, we will strengthen the clinical knowledge and preventive health care knowledge of chronic disease managers. Combined with the Centers for Disease Control and Prevention training, chronic disease management personnel are allowed to participate in relevant health management training courses organized by superior departments to effectively improve personnel's health management capabilities.

6. Coordinate with other temporary tasks.

With the government’s investment in chronic disease prevention and treatment and the improvement of residents’ health awareness, community chronic disease management plays an increasingly important role in community health services. We summarize the progress of chronic disease management in 20xx Based on our experience and shortcomings, in 20xx we will continue to work hard to improve our chronic disease management capabilities and explore new chronic disease management models suitable for our center. ;