電子健康檔案管理：通過數(shù)字化手段收集、存儲和共享患者的健康信息，便于醫(yī)生監(jiān)測病情變化。利用信息系統(tǒng)記錄并追蹤患者的基本資料、既往病史及用藥情況等，以便及時(shí)調(diào)整治療方案。

　　Electronic Health Record Management: Collecting, storing, and sharing patients' health information through digital means to facilitate doctors in monitoring changes in their condition. Utilize information systems to record and track patients' basic information, medical history, medication use, etc., in order to adjust treatment plans in a timely manner.

　　定期面對面評估：通過與患者直接交流，了解其心理狀態(tài)及行為模式，有助于早期發(fā)現(xiàn)異常信號。安排固定時(shí)間進(jìn)行面對面訪談，確保信息準(zhǔn)確性和完整性。

　　Regular face-to-face assessment: By directly communicating with patients, understanding their psychological state and behavioral patterns can help detect abnormal signals early. Schedule a fixed time for face-to-face interviews to ensure accuracy and completeness of information.

　　社區(qū)支持網(wǎng)絡(luò)：構(gòu)建互助小組或聯(lián)系當(dāng)?shù)匦睦斫】到M織，為患者創(chuàng)造一個(gè)安全且有歸屬感的環(huán)境。鼓勵患者參與集體活動以促進(jìn)人際交往，并接受來自同儕群體的理解與幫助。

　　Community support network: Build mutual aid groups or contact local mental health organizations to create a safe and belonging environment for patients. Encourage patients to participate in group activities to promote interpersonal communication and accept understanding and help from peer groups.

　　家庭訪視教育：由專業(yè)人員對家屬進(jìn)行培訓(xùn)，使其掌握識別早期癥狀和應(yīng)對策略。定期上門開展講座或個(gè)別指導(dǎo)，提高家人識別風(fēng)險(xiǎn)因素的能力。

　　Family visit education: Professional personnel provide training to family members to enable them to identify early symptoms and coping strategies. Regularly conduct on-site lectures or individual guidance to enhance family members' ability to identify risk factors.

　　藥物治療管理：跟蹤服藥情況，確保按時(shí)按量服用處方藥物，監(jiān)控可能影響患者依從性的因素，并采取相應(yīng)措施改善。

　　Drug therapy management: track medication status, ensure timely and adequate use of prescribed drugs, monitor factors that may affect patient compliance, and take corresponding measures to improve.

　　入戶隨訪：醫(yī)務(wù)人員攜帶血壓計(jì)、血糖儀及健康宣傳冊，對社區(qū)居民進(jìn)行逐戶上門隨訪。詳細(xì)詢問患者的健康情況、生活習(xí)慣、飲食、服藥情況，進(jìn)行健康評估，并指導(dǎo)慢性病患者正確服藥，保持合理膳食、適量運(yùn)動、戒煙限酒、良好的心態(tài)和健康的生活方式。

　　Household follow-up: Medical staff carry blood pressure monitors, blood glucose meters, and health brochures to conduct door-to-door follow-up visits to community residents. Inquire in detail about the patient's health status, lifestyle habits, diet, and medication status, conduct a health assessment, and guide chronic disease patients to take medication correctly, maintain a reasonable diet, moderate exercise, quit smoking and limit alcohol consumption, maintain a good mentality, and adopt a healthy lifestyle.

　　電話或微信隨訪：通過電話、微信等方式定期了解患者病情變化和指導(dǎo)患者康復(fù)。近期隨訪主要觀察患者治療的效果及用藥反應(yīng)，根據(jù)隨訪情況和復(fù)查結(jié)果來調(diào)整用藥；遠(yuǎn)期隨訪可以獲得患者治療方案的長期效果、遠(yuǎn)期并發(fā)癥，有利于篩選出更有效的治療方法。

　　Telephone or WeChat follow-up: Regularly monitor changes in the patient's condition and guide their recovery through telephone, WeChat, and other means. The recent follow-up mainly observes the treatment effect and medication response of patients, and adjusts medication according to the follow-up situation and re examination results; Long term follow-up can obtain the long-term effects and complications of the patient's treatment plan, which is beneficial for screening more effective treatment methods.

　　健康教育服務(wù)：提供健康教育資料、設(shè)置健康教育宣傳欄、開展公眾健康咨詢活動、舉辦健康知識講座、開展個(gè)體化健康教育等，提高居民的健康意識和自我管理能力。

　　Health education services: providing health education materials, setting up health education bulletin boards, conducting public health consultation activities, holding health knowledge lectures, conducting personalized health education, etc., to enhance residents' health awareness and self-management ability.

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