CAJ | 학술논문

目的对高血压糖尿病病人进行规范化管理。方法根据《成都市基层医疗卫生机构基本公共卫生服务C类服务包（2010版、2011版、2012版）绩效考核标准——工作指标》的要求，根据中心的实际情况，有组织、有计划地实施慢病管理工作。结果高血压和糖尿病建卡建册分别为4203人和907人，完成规范随访分别为3917人和854人，管理率分别为93.2%和94.16%。经全程干预高血压控制（优良尚可）2896人（74.98%），糖尿病控制623人（79.56%）。城乡居民规范化建档率达76.22%、社区健康促进与健康教育、群众满意度和可信度大幅度提高。结论慢性病规范管理能体现政府对百姓的关怀，提高居民的健康保健和自我防病治病意识，促进社区和谐进步。
목적대고혈압당뇨병병인진행규범화관리。방법근거《성도시기층의료위생궤구기본공공위생복무C류복무포（2010판、2011판、2012판）적효고핵표준——공작지표》적요구，근거중심적실제정황，유조직、유계화지실시만병관리공작。결과고혈압화당뇨병건잡건책분별위4203인화907인，완성규범수방분별위3917인화854인，관리솔분별위93.2%화94.16%。경전정간예고혈압공제（우량상가）2896인（74.98%），당뇨병공제623인（79.56%）。성향거민규범화건당솔체76.22%、사구건강촉진여건강교육、군음만의도화가신도대폭도제고。결론만성병규범관리능체현정부대백성적관부，제고거민적건강보건화자아방병치병의식，촉진사구화해진보。
Objective Purpose of standardized management of hypertension in diabetic patients. Method In accordance with the basic medical and health institutions of basic public health services in Chengdu city class c Service Pack (version 2010) performance evaluation criteria - specification of requirements, according to the actual situation of the Centre, organized and planned to implement the management of chronic diseases. Results Cards built in hypertension and diabetes mellitus and 907 people were 4203 people, follow-up of completed specification is 3917 and 854 respectively, manage rates 93.2% and 94.16%, respectively. By the intervention of hypertension control (excellent) 2,896 people (74.98%), 623 diabetes control (79.56%). Standardized filing rate of 76.22% of urban and rural residents, community health education, health promotion and credibility and dramatically increase the satisfaction of the masses. Findings chronic disease management to reflect the Government's concern for the people, improve the health of residents and self awareness to prevent and cure diseases, promote community harmony and progress.