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2023-08-17
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ÕªÒª£º 1) ΣÏÕÒòËØ·¢Ã÷1) Risk factor discoveryƾ֤¡¶ÌìÏÂÂýÐÔ²¡Ô¤·À¿ØÖÆÊÂÇé¹æ·¶£¨ÊÔÐУ©2011°æ¡·µÚËÄÕ¸ÉÔ¤ÓëÖÎÀíÖÐÖ¸³ö£ºÂýÐÔ²¡¸ßΣº¦ÈË
1) ΣÏÕÒòËØ·¢Ã÷
1) Risk factor discovery
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According to Chapter 4 "Intervention and Management" of the "National Norms for Chronic Disease Prevention and Control (Trial) 2011 Edition", it is pointed out that high-risk individuals with chronic diseases are those with one of the following characteristics:
£¨1£©ÑªÑ¹Ë®Æ½Îª130-139/85-89mmHg £»
(1) The blood pressure level is 130-139/85-89mHg;
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(2) Current smokers;
£¨3£©¿Õ¸¹ÑªÌÇˮƽΪ£º6.1 ≤ FBG<7.0mmol/L £»
(3) The fasting blood glucose level is 6.1 ≤ FBG<7.0mmol/L;
£¨4£©ÑªÇå×ܵ¨¹Ì´¼Ë®Æ½Îª£º5.2 ≤ TC<6.2mmol/L £»
(4) The serum total cholesterol level is 5.2 ≤ TC<6.2mmol/L;
£¨5£©ÄÐÐÔÑüΧ≥ 90cm £¬Å®ÐÔÑüΧ≥ 85cm¡£
(5) Male waist circumference ≥ 90cm, female waist circumference ≥ 85cm.
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Individuals with three or more characteristics should be included in the scope of individual health management
2) Âý²¡¼à²âÓëÖÎÀí
2) Chronic disease monitoring and management
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Community health service centers (stations) are carrying out the standardized management of chronic diseases focusing on "hypertension", "diabetes", "coronary heart disease", "stroke", and "malignant tumor". The construction of the "health house" should be able to provide the auxiliary role of standardized management for this part of the key population. For example, regular measurement of hypertension and blood sugar will help to timely grasp the control effect of hypertension patients and diabetes patients, Timely discovery and guidance.
3) ¿µ½¡ÆÀ¹ÀÓëÖ¸µ¼
3) Health assessment and guidance
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Health management is different from disease management. Health management is mainly based on the current physical condition, identifying risk factors, integrating the current lifestyle, conducting comprehensive assessments, and providing health promotion guidance to achieve early prevention, treatment, and prevention of diseases. Starting from the cornerstone of prevention and control of health, such as "reasonable diet, moderate exercise, smoking and alcohol cessation, psychological balance, and health preservation".
4) ¹«¹²ÎÀÉúЧÀÍ
4) Public health services
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The construction of health huts in communities can improve the quality of national basic public health services, mainly reflected in "daily health examinations for residents", "disease screening statistics", "chronic disease prevention and control", "rehabilitation assistance", "health education", "health consultation", and "health management services".
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4¡¢ Health Cabin Service Process
1) ͨ¹ýÔÚϲãÒ½ÁÆÎÀÉúЧÀÍ»ú¹¹¡¢¾Óί»á¡¢½ÖµÀ°ìµÈ¹«¹²Ð§À͵ã £¬°²ÅÅÖÇÄÜÌå¼ì»ú £¬ÊÕÂÞסÃñµÄ¿µ½¡ÌåÕ÷Êý¾Ý£¨Éí¸ß¡¢ÌåÖØ¡¢ÑªÑ¹¡¢ÂöÂÊ¡¢BMIµÈ£© £¬×Ô¶¯´«ÊäסÃñ¿µ½¡ÖÎÀíÐÅϢƽ̨£¨ÇøÓòÎÀÉúÐÅϢϵͳƽ̨£© £¬ÍÆËÍÉçÇøÒ½£¨¼ÒÍ¥Ò½Éú£©µÄÊÂÇéƽ̨¡£
1) By deploying intelligent physical examination machines at public service points such as grassroots medical and health service institutions, neighborhood committees, and street offices, residents' health sign data (height, weight, blood pressure, pulse rate, BMI, etc.) is collected and automatically transmitted to the residents' health management information platform (regional health information system platform), and pushed to the work platform of community doctors (family doctors).
2) Ìå¼ìʱ £¬ÏòסÃñºÍÉçÇøÖÎÀíÕß·¢³ö¿µ½¡Òì³£Ö¸±êÌáÐÑ¡£
2) During the physical examination, issue health abnormality indicators to residents and community managers.
3) ÉçÇøÒ½Éú²éÔÄסÃñµÄ¿µ½¡ÌåÕ÷ÕÉÁ¿Êý¾Ý £¬ÌṩÏìÓ¦¿µ½¡Ö¸µ¼¡£¿ÉÍŽáÐÅϢƽ̨ת·¢×¡ÃñСÎÒ˽¼Ò¡¢×¡Ãñ¾ìÊô £¬¼û¸æ¿µ½¡×´Ì¬¡£
3) Community doctors consult residents' health sign measurement data and provide corresponding health guidance. It can be forwarded to individual residents and their families through information platforms to inform them of their health status.
4) סÃñСÎÒ˽¼Ò¡¢×¡Ãñ¾ìÊô¿ÉµÇ¼ÏìÓ¦µÄ¿µ½¡ÐÅϢƽ̨²éÔÄСÎÒ˽¼ÒµÄÌåÕ÷ÕÉÁ¿Êý¾Ý¼°¿µ½¡Ö¸µ¼½¨Òé¡£
4) Individuals and family members of residents can log in to the corresponding health information platform to view their physical sign measurement data and health guidance suggestions.
5) ƽ̨ÓëÇøÓòµÄ¿µ½¡µµ°¸ÏµÍ³¶Ô½Ó £¬Ôö²¹×¡ÃñµÄ¿µ½¡µµ°¸¡£
5) The platform interfaces with the regional health record system to supplement residents' health records.
6) ÇøÓòÖÎÀíÕßƾ֤ÐÅϢƽ̨Êý¾Ý £¬ÖªÏþÇøÓòÄÚסÃñ¿µ½¡ÐÅϢ״̬ £¬Îª¹«¹²ÎÀÉúЧÀÍÌṩӪҵÊý¾Ý¡£
6) Regional managers are informed of the health information status of residents in the region based on information platform data, and provide business data for public health services.
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