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为了探讨加强老年高血压患者的健康档案管理对其自我管理行为的影响,提高患者对高血压的知晓率、治疗率、控制率。对2012年本社区卫生服务中心所辖8个居委会新增的60岁以上的138名老年高血压患者建立个人健康档案,并按照《国家基本公共卫生服务规范(2011版)》慢性病管理标准进行规范化的随访。给予用药指导、生活指导、疾病相关知识的健康教育等。坚持规范随访二年后,用自行设计的调查问卷就高血压患者的自我管理情况进行调查。结果显示:通过建立健康档案和规范随访二年后,患者定期自我监测血压、规律服药、合理膳食、主动运动等自我管理的行为明显增强。由此可见,对高血压患者建立健康档案,并加强规范化随访、科学指导,能够有效地促进高血压患者的自我管理行为明显提高。
In order to explore the impact of strengthening the management of health records of elderly hypertensive patients on their self-management behaviors and to improve their awareness of hypertension, treatment rate and control rate. To establish a personal health record of 138 elderly hypertensive patients over the age of 60 who were newly added by 8 neighborhood committees under the jurisdiction of the community health service center in 2012 and to be standardized according to the national basic public health service standard (2011 version) chronic disease management standard Follow-up. Give medication guidance, life guidance, disease-related knowledge of health education. After two years of adherence to normative follow-up, self-designed questionnaires were used to investigate the self-management of hypertensive patients. The results showed that self-management behaviors such as regular self-monitoring of blood pressure, regular medication, reasonable diet, active exercise and so on were significantly enhanced after establishment of health records and standard follow-up two years later. Thus, the establishment of health files for hypertensive patients, and to strengthen the standardization of follow-up, scientific guidance, can effectively promote the self-management of patients with hypertension increased significantly.