基于医防融合的慢病患者管理SOP的构建与实践

doi:10.3760/cma.j.issn.1007-1245.2024.20.030

国际医药卫生导报 ›› 2024, Vol. 30 ›› Issue (20): 3497-3502.DOI: 10.3760/cma.j.issn.1007-1245.2024.20.030

基于医防融合的慢病患者管理SOP的构建与实践

尹娜¹ 叶伟坚² 张国良³ 梁赤波⁴ 刘汉海¹ 罗茹怀¹

¹东莞市长安镇社区卫生服务中心，东莞　523843；²东莞市卫生健康局基层卫生健康科，东莞　523076；³东莞市寮步镇社区卫生服务中心，东莞　523000；⁴东莞市社区卫生服务管理中心，东莞　523000

收稿日期:2023-10-07 出版日期:2024-10-01 发布日期:2024-10-19
通讯作者: 叶伟坚，Email：871386313@qq.com
基金资助:
东莞市科技计划（20211800904232）

Construction and practice of SOP management for patients with chronic diseases based on medicine and prevention integration

Yin Na¹, Ye Weijian², Zhang Guoliang³, Liang Chibo⁴, Liu Hanhai¹, Luo Ruhuai¹

¹Dongguan Chang'an Community Health Service Center, Dongguan 523843, China; ²Primary Health Department, Dongguan Municipal Health Bureau, Dongguan 523076, China; ³Dongguan Liaobu Community Health Service Center, Dongguan 523000, China; ⁴Dongguan City Community Health Service Management Center, Dongguan 523000, China

Received:2023-10-07 Online:2024-10-01 Published:2024-10-19
Contact: Ye Weijian, Email: 871386313@qq.com
Supported by:
Dongguan Science and Technology Plan (20211800904232)

摘要/Abstract

摘要：

目的　探讨医防融合下的慢性疾病（慢病）患者管理标准操作规程（standard operating procedure，SOP）的构建与实践效果。方法　回顾性分析2022年10月至2023年3月期间东莞市长安镇社区卫生服务中心413例慢病患者的门诊就诊与随访情况，将413例患者按管理方法分为常规组263例和标准化组150例。常规组男178例，女85例，年龄（45.69±7.24）岁，纳入社区慢病管理时长（4.57±1.65）年，高血压152例、2型糖尿病74例、高血压合并2型糖尿病37例；标准化组男89例，女61例，年龄（44.28±8.65）岁，纳入社区慢病管理时长（4.39±1.43）年，高血压95例、2型糖尿病37例、高血压合并2型糖尿病18例。常规组采用常规管理，标准化组在常规管理基础上构建并实施医防融合一体的全科诊疗与随访SOP。比较两组门诊病历、随访表书写质量，诊疗随访时长、服药依从性、患者满意度、患者知晓率、医护人员满意度。采用χ²检验、独立样本t检验。结果　标准化组的门诊病历和随访表的书写质量均高于常规组［（92.31±5.89）分比（85.23±4.68）分、（93.54±6.24）分比（87.27±5.67）分］，差异均有统计学意义（均P<0.001）。标准化组的诊疗随访时长、服药依从性均优于常规组，差异均有统计学意义（均P<0.05）。标准化组的患者满意度、知晓率及医护人员满意度均高于常规组［98.00%（147/150）比84.79%（223/263）、98.66%（148/150）比84.79%（223/263）、95.00%（19/20）比71.73%（99/138）］，差异均有统计学意义（均P<0.05）。结论　医防融合下慢病患者管理SOP可有效提升社区卫生服务中心全科诊疗能力，融洽医患关系，提高患者自我管理依从性，提高工作效率、提高医护人员职业认同，改善患者服务体验。

关键词:

全科诊疗, 慢病随访, 医防融合, 标准操作规程, 构建, 社区卫生服务中心

Abstract:

Objective　To explore the standard operating procedure (SOP) construction and practice effect on patients with chronic diseases under the integration of medical treatment and prevention. Methods　The outpatient visits and follow-up of 413 patients with chronic diseases in Dongguan Chang'an Community Health Service Center from October 2022 to March 2023 were retrospectively analyzed, and the 413 patients were divided into a routine group (263 cases) and a standardized group (150 cases) according to the management methods. In the routine group, there were 178 males and 85 females, aged (45.69±7.24) years, they had been included in the community chronic disease management for (4.57±1.65) years, and there were 152 cases of hypertension, 74 cases of type 2 diabetes mellitus (T2DM), and 37 cases of hypertension complicated with T2DM. In the standardized group, there were 89 males and 61 females, aged (44.28±8.65) years, they had been included in the community chronic disease management for (4.39±1.43) years, and there were 95 cases of hypertension, 37 cases of T2DM, and 18 cases of hypertension complicated with T2DM. The routine group adopted the routine management, and the standardized group constructed and implemented the general practice diagnosis and follow-up SOP under the integration of medical treatment and prevention on the basis of the routine management. The writing qualities of outpatient medical records and follow-up forms, duration of follow-up, medication compliance, patient satisfaction, patient awareness, and satisfaction of medical staff were compared between the two groups. χ² test and independent sample t test were used. Results　The writing qualities of outpatient medical records and follow-up forms in the standardized group were higher than those in the routine group [(92.31±5.89) points vs. (85.23±4.68) points, (93.54±6.24) points vs. (87.27±5.67) points], with statistically significant differences (both P<0.001). The duration of follow-up and medication compliance of the standardized group were better than those of the routine group, with statistically significant differences (both P<0.05). The patient satisfaction, patient awareness, and satisfaction of medical staff in the standardized group were higher than those in the routine group [98.00% (147/150) vs. 84.79% (223/263), 98.66% (148/150) vs. 84.79% (223/263), 95.00% (19/20) vs. 71.73% (99/138)], with statistically significant differences (all P<0.05). Conclusion　The SOP of chronic disease management under the integration of medicine and prevention can effectively improve the diagnosis and treatment ability of general practice of community health service center, harmonize the relationship between doctors and patients, improve the patients' self-management compliance, improve the work efficiency, improve the professional identity of medical staff, and improve the patients' service experience.

Key words:

General practice diagnosis and treatment, Follow up of chronic diseases, Integration of medicine and prevention, Standard operating procedure, Construction, Community health service center

尹娜叶伟坚张国良梁赤波刘汉海罗茹怀.

基于医防融合的慢病患者管理SOP的构建与实践 [J]. 国际医药卫生导报, 2024, 30(20): 3497-3502.

Yin Na, Ye Weijian, Zhang Guoliang, Liang Chibo, Liu Hanhai, Luo Ruhuai.

Construction and practice of SOP management for patients with chronic diseases based on medicine and prevention integration [J]. International Medicine and Health Guidance News, 2024, 30(20): 3497-3502.

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基于医防融合的慢病患者管理SOP的构建与实践

Construction and practice of SOP management for patients with chronic diseases based on medicine and prevention integration

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