慢性病患者隨訪?

Follow up of chronic disease patients

慢性病患者需要長期、持續的健康管理。公衛隨訪人員攜帶隨訪包，定期上門為高血壓、糖尿病患者測量血壓、血糖，了解病情控制情況，指導患者正確用藥，并根據檢查結果調整治療方案。通過面對面交流，工作人員還能向患者傳授健康飲食、適量運動等方面的知識，增強患者的自我管理意識，提高疾病控制效果。?

Chronic disease patients require long-term and continuous health management. The public health follow-up personnel carry the follow-up bag, regularly come to the door to measure blood pressure and blood sugar for patients with hypertension and diabetes, understand the condition control, guide patients to use drugs correctly, and adjust the treatment plan according to the inspection results. Through face-to-face communication, staff can also impart knowledge on healthy eating and moderate exercise to patients, enhance their self-management awareness, and improve disease control effectiveness. ?

孕產婦和兒童健康管理?

Maternal and Child Health Management

對于孕產婦，隨訪人員在不同孕期上門進行檢查，使用隨訪包中的設備測量孕婦的血壓、體重，聽胎心，了解孕期身體狀況，給予孕期保健指導。產后，還會對產婦和新生兒進行訪視，檢查新生兒的身體發育情況，指導產婦進行母乳喂養和產后康復。在兒童健康管理方面，工作人員通過定期測量兒童的身高、體重，進行生長發育評估，及時發現生長發育異常，為兒童健康成長保駕護航。?

For pregnant women, follow-up personnel visit their homes at different stages of pregnancy for examinations. They use the equipment in the follow-up package to measure the pregnant woman's blood pressure and weight, listen to fetal heart rate, understand the physical condition during pregnancy, and provide guidance on prenatal care. After childbirth, we will also visit the mother and newborn to check their physical development and guide them in breastfeeding and postpartum recovery. In terms of children's health management, staff regularly measure children's height and weight, conduct growth and development assessments, and promptly detect abnormal growth and development, providing protection for children's healthy growth. ?

傳染病防控隨訪?

Follow up on infectious disease prevention and control

在傳染病防控工作中，公衛隨訪包同樣發揮著重要作用。隨訪人員對傳染病患者或密切接觸者進行追蹤隨訪，測量體溫，了解癥狀變化，及時發現病情進展，為疫情防控提供依據。同時，向患者和密切接觸者宣傳傳染病防控知識，指導其做好個人防護和隔離措施，防止疫情傳播。?

In the prevention and control of infectious diseases, the public health follow-up package also plays an important role. Follow up personnel track and follow up infectious disease patients or close contacts, measure body temperature, understand symptom changes, timely detect disease progression, and provide a basis for epidemic prevention and control. At the same time, promote infectious disease prevention and control knowledge to patients and close contacts, guide them to take personal protective and isolation measures, and prevent the spread of the epidemic. ?

三、規范使用：發揮隨訪包最大效能?

3、 Standardized use: maximize the effectiveness of follow-up packages

準備階段?

Preparation stage

在開展隨訪工作前，工作人員要對公衛隨訪包進行全面檢查，確保設備功能正常、耗材充足。同時，了解隨訪對象的基本信息，制定個性化的隨訪計劃，明確隨訪目的和重點內容。?

Before conducting follow-up work, staff should conduct a comprehensive inspection of the public health follow-up package to ensure that the equipment is functioning properly and consumables are sufficient. At the same time, understand the basic information of the follow-up subjects, develop personalized follow-up plans, clarify follow-up purposes and key content. ?

現場隨訪?

On site follow-up

到達隨訪現場后，工作人員要先向隨訪對象說明來意，取得對方的配合。按照規范操作流程，使用隨訪包中的設備進行各項檢查，認真記錄檢查結果。在交流過程中，耐心傾聽隨訪對象的訴求，解答他們的健康疑問，發放健康宣傳資料，引導其養成健康的生活方式。?

After arriving at the follow-up site, the staff should first explain the purpose of the visit to the follow-up object and obtain their cooperation. According to the standard operating procedures, use the equipment in the follow-up package for various inspections and carefully record the inspection results. During the communication process, patiently listen to the demands of the follow-up subjects, answer their health questions, distribute health promotion materials, and guide them to develop a healthy lifestyle. ?

隨訪后工作?

Follow up work

隨訪結束后，工作人員要及時對隨訪數據進行整理和分析，將檢查結果錄入公共衛生管理系統，為后續的健康管理提供數據支持。對發現的健康問題，及時進行反饋和處理，必要時安排轉診治療。同時，對公衛隨訪包進行清潔和消毒，補充耗材，為下一次隨訪做好準備。??

After the follow-up is completed, the staff should promptly organize and analyze the follow-up data, enter the examination results into the public health management system, and provide data support for subsequent health management. Promptly provide feedback and handle any health issues discovered, and arrange for referral for treatment if necessary. At the same time, clean and disinfect the public health follow-up package, replenish consumables, and prepare for the next follow-up. ??

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