CAJ | 학술논문

调查徐家汇社区卫生服务中心下属中心团队与塘子泾团队在社区开展慢性病管理的情况,发现社区全科团队在工作中面临以下问题:①随访工作任务繁重和医务人员相对不足;②社区居民健康理念不科学,对开展慢性病预防管理的重要性认识不足;③慢性病信息管理系统建设滞后,效率不高.针对慢性病管理工作相关问题,对提高社区慢性病管理效果的对策进行探讨.
조사서가회사구위생복무중심하속중심단대여당자경단대재사구개전만성병관리적정황,발현사구전과단대재공작중면림이하문제:①수방공작임무번중화의무인원상대불족;②사구거민건강이념불과학,대개전만성병예방관리적중요성인식불족;③만성병신식관리계통건설체후,효솔불고.침대만성병관리공작상관문제,대제고사구만성병관리효과적대책진행탐토.
In a survey on chronic disease management in Xujiahui Community,we found that the general practice team was facing the following problems：①Heavy burden of follow-up work by a relatively smaller number of physicians;②Misunderstanding of health and insufficient recognition of the importance of chronic disease management among community residents;and③Delayed database construction and inefficient performance.In this study,we described the strategies to improve chronic disease management in communities.