医护搭配,健康管理有新招

2017-09-28 陈锐 医师在线

随着《国家基本公共卫生服务规范(2017年版)》的推出,并结合家庭医生团队签约的各项要求,单独的一个医生或者护士已经越来越无法胜任社区居民健康管理的实际需求。鉴于实际工作需要以及各项规定要求,我中心开展了医生与护士相互协作的新搭档模式,进行社区居民健康管理的新尝试,以共同完成社区居民的基本医疗和基本公共卫生健康需求。

随着《国家基本公共卫生服务规范(2017年版)》的推出,并结合家庭医生团队签约的各项要求,单独的一个医生或者护士已经越来越无法胜任社区居民健康管理的实际需求。鉴于实际工作需要以及各项规定要求,我中心开展了医生与护士相互协作的新搭档模式,进行社区居民健康管理的新尝试,以共同完成社区居民的基本医疗和基本公共卫生健康需求。

医护协作团队是在我中心现有的7支家庭医生小组的基础上进行细分,并最终形成15支由一医一护或者两医一护构成的医护协作团队。其中,每个医护协作团队由医生担任团队长,负责本团队的各项工作计划与安排,并负责该团队绩效考核工作的进行。

人员分工

家庭医生

负责本医护协作团队的所有基本医疗和公共卫生工作,包括具体工作的分工安排、质控以及绩效。

需要完成本组管理居民的高血压糖尿病等慢性疾病的基础体检以及用药指导,并负责65岁以上老年人的内外科体检,还要指导本组护士开展居民的中医体质辨识以及健康教育工作。

社区护士

协助家庭医生开展社区健康管理,其工作任务由工作室家庭医生来安排和分配,即担任家庭医生的助手角色。

需要完成管理高血压糖尿病等慢性疾病患者的身高、体重测量以及发放65岁以上老年人的健康体检通知,并完成65岁以上老年人的中医体质辨识工作和负责本团队重点人群的建档、访视以及录入工作。此外,还要承担本组家庭医生所负责基本医疗患者的预约挂号和分诊工作。

人员责任

家庭医生和社区护士共同管理所辖社区的重点人群以及医生门诊医疗的重点人群,并明确规定重点人群的规范管理责任在医生,重点人群的访视、录入规范责任在护士。

基于以上医护协作的人员分工和配置,我们开展了各项基本公共卫生和基本医疗工作,下面举两个例子。

慢病健康管理

门诊就诊慢病患者访视由家庭医生完成,非门诊的辖区慢病患者由社区护士协作家庭医生完成。对于有调药需求、慢病咨询以及需要入户访视的居民,由社区护士联系家庭医生共同上门进行。

慢病患者的所有基础体检安排在每年第一季度由医护协作团队制定工作进度计划,家庭医生负责心、肺听诊等基础体检,并每月就访视以及体检等具体完成情况由医护协作团队长报送工作量到中心。

老年人健康管理

辖区老年人的健康管理属于门诊患者的由家庭医生负责完成,属于辖区非门诊居民的由社区护士负责完成,对于有医疗需求的老年人由社区护士联系家庭医生共同完成健康管理。

另外,社区护士负责预约社区老年人到中心开展老年人体检项目;在体检过程中,家庭医生则负责老年人的内外科体检以及对生化、血常规、影像等体检结果的解读

小结

综上,通过配置微型化的医护协作团队,能够很好地发挥医生和护士的长处,同时能够通过医护协作,实现强强联合,共同维护社区居民的健康管理。

医护协作模式可以突出医生的主体作用,强化医生的基本医疗属性;且通过社区护士的协助,一方面可让社区居民在基本公共卫生方面有更大的认同感,另一方面由于医护之间的紧密协作,又能让社区居民在第一时间内获得更好的基本医疗服务。

总之,医生和护士通过这种协助方式能够更好地完成各项基本医疗和基本公共卫生的要求,并更好地促进社区居民健康管理工作的开展,更加扎实地做好社区居民的“健康守门人”。

文/陈锐(成都市青羊区新华少城社区卫生服务中心全科诊疗科主治医师)

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    2021-11-20 湘雅科教

    已阅,受益匪浅。

    0

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    2017-09-30 陈方郑

    喜欢的就觉得记得记得科技大

    0

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    2017-09-29 1e1ff052m13(暂无匿称)

    学习了学习了

    0

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    2017-09-28 1e0f8808m18(暂无匿称)

    健康管理的好模式.

    0

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    2017-09-28 1e1ff052m13(暂无匿称)

    好.学习了学习了

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1072081, encodeId=6a5710e2081df, content=已阅,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Sat Nov 20 10:20:52 CST 2021, time=2021-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=249077, encodeId=11e82490e79e, content=喜欢的就觉得记得记得科技大, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83erHmiaPStHsBjHGm3Y4ZHHanFXRDgAiaEiabOGdC4Q6KfAYrmmuicVyBk7YMJOMXTuQnIpZqReTiceibjdg/132, createdBy=2ab92087896, createdName=陈方郑, createdTime=Sat Sep 30 10:20:17 CST 2017, time=2017-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1447481, encodeId=a18a144e481c9, content=<a href='/topic/show?id=9fda2e9116b' target=_blank style='color:#2F92EE;'>#健康管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=27911, encryptionId=9fda2e9116b, topicName=健康管理)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJ9crP64ayyDcSQOGicWw0ZRm4U8ZDjCkz9hMomMn0r5pAjfw6ibsdjRlWaf2jTibwibdxyFu9kyu2iauw/132, createdBy=a33d5357253, createdName=windight, createdTime=Fri Sep 29 15:41:00 CST 2017, time=2017-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248653, encodeId=c5d6248653f5, content=学习了学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55a22015915, createdName=1e1ff052m13(暂无匿称), createdTime=Fri Sep 29 00:41:46 CST 2017, time=2017-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248597, encodeId=552724859e78, content=健康管理的好模式., beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Thu Sep 28 22:00:17 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248477, encodeId=0ab22484e722, content=好.学习了学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55a22015915, createdName=1e1ff052m13(暂无匿称), createdTime=Thu Sep 28 08:43:20 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248473, encodeId=16bc2484e3b9, content=形式多样的管理, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Thu Sep 28 08:36:48 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248466, encodeId=78a5248466f5, content=是很好的学习材料.不错.以后会多学习., beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzUn81b5CF5ibVPib8jWI92iciaxmqGHlwruOnK4SVZykd4iahqo1hicklIibyZoxm55X7EM8BW9eX1h1hQ2/0, createdBy=8aa81937526, createdName=李东泽, createdTime=Thu Sep 28 08:16:39 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248460, encodeId=275e24846059, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyhb9xDeHojCicsdRdyC3XXdGk2ib9yLypZuHN06WeW4HO8WN0GGrgEfvnTX8gsckof05GHOU5OM4Mvx/0, createdBy=9cee1982656, createdName=执着追梦, createdTime=Thu Sep 28 07:54:35 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248459, encodeId=c07e24845958, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e7f41959343, createdName=1e131038m59(暂无匿称), createdTime=Thu Sep 28 07:51:32 CST 2017, time=2017-09-28, status=1, ipAttribution=)]
    2017-09-28 lyh994

    形式多样的管理

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1072081, encodeId=6a5710e2081df, content=已阅,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Sat Nov 20 10:20:52 CST 2021, time=2021-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=249077, encodeId=11e82490e79e, content=喜欢的就觉得记得记得科技大, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83erHmiaPStHsBjHGm3Y4ZHHanFXRDgAiaEiabOGdC4Q6KfAYrmmuicVyBk7YMJOMXTuQnIpZqReTiceibjdg/132, createdBy=2ab92087896, createdName=陈方郑, createdTime=Sat Sep 30 10:20:17 CST 2017, time=2017-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1447481, encodeId=a18a144e481c9, content=<a href='/topic/show?id=9fda2e9116b' target=_blank style='color:#2F92EE;'>#健康管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=27911, encryptionId=9fda2e9116b, topicName=健康管理)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJ9crP64ayyDcSQOGicWw0ZRm4U8ZDjCkz9hMomMn0r5pAjfw6ibsdjRlWaf2jTibwibdxyFu9kyu2iauw/132, createdBy=a33d5357253, createdName=windight, createdTime=Fri Sep 29 15:41:00 CST 2017, time=2017-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248653, encodeId=c5d6248653f5, content=学习了学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55a22015915, createdName=1e1ff052m13(暂无匿称), createdTime=Fri Sep 29 00:41:46 CST 2017, time=2017-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248597, encodeId=552724859e78, content=健康管理的好模式., beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Thu Sep 28 22:00:17 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248477, encodeId=0ab22484e722, content=好.学习了学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55a22015915, createdName=1e1ff052m13(暂无匿称), createdTime=Thu Sep 28 08:43:20 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248473, encodeId=16bc2484e3b9, content=形式多样的管理, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Thu Sep 28 08:36:48 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248466, encodeId=78a5248466f5, content=是很好的学习材料.不错.以后会多学习., beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzUn81b5CF5ibVPib8jWI92iciaxmqGHlwruOnK4SVZykd4iahqo1hicklIibyZoxm55X7EM8BW9eX1h1hQ2/0, createdBy=8aa81937526, createdName=李东泽, createdTime=Thu Sep 28 08:16:39 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248460, encodeId=275e24846059, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyhb9xDeHojCicsdRdyC3XXdGk2ib9yLypZuHN06WeW4HO8WN0GGrgEfvnTX8gsckof05GHOU5OM4Mvx/0, createdBy=9cee1982656, createdName=执着追梦, createdTime=Thu Sep 28 07:54:35 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248459, encodeId=c07e24845958, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e7f41959343, createdName=1e131038m59(暂无匿称), createdTime=Thu Sep 28 07:51:32 CST 2017, time=2017-09-28, status=1, ipAttribution=)]
    2017-09-28 李东泽

    是很好的学习材料.不错.以后会多学习.

    0

  9. [GetPortalCommentsPageByObjectIdResponse(id=1072081, encodeId=6a5710e2081df, content=已阅,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Sat Nov 20 10:20:52 CST 2021, time=2021-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=249077, encodeId=11e82490e79e, content=喜欢的就觉得记得记得科技大, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83erHmiaPStHsBjHGm3Y4ZHHanFXRDgAiaEiabOGdC4Q6KfAYrmmuicVyBk7YMJOMXTuQnIpZqReTiceibjdg/132, createdBy=2ab92087896, createdName=陈方郑, createdTime=Sat Sep 30 10:20:17 CST 2017, time=2017-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1447481, encodeId=a18a144e481c9, content=<a href='/topic/show?id=9fda2e9116b' target=_blank style='color:#2F92EE;'>#健康管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=27911, encryptionId=9fda2e9116b, topicName=健康管理)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJ9crP64ayyDcSQOGicWw0ZRm4U8ZDjCkz9hMomMn0r5pAjfw6ibsdjRlWaf2jTibwibdxyFu9kyu2iauw/132, createdBy=a33d5357253, createdName=windight, createdTime=Fri Sep 29 15:41:00 CST 2017, time=2017-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248653, encodeId=c5d6248653f5, content=学习了学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55a22015915, createdName=1e1ff052m13(暂无匿称), createdTime=Fri Sep 29 00:41:46 CST 2017, time=2017-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248597, encodeId=552724859e78, content=健康管理的好模式., beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=60791943465, createdName=1e0f8808m18(暂无匿称), createdTime=Thu Sep 28 22:00:17 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248477, encodeId=0ab22484e722, content=好.学习了学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=55a22015915, createdName=1e1ff052m13(暂无匿称), createdTime=Thu Sep 28 08:43:20 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248473, encodeId=16bc2484e3b9, content=形式多样的管理, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Thu Sep 28 08:36:48 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248466, encodeId=78a5248466f5, content=是很好的学习材料.不错.以后会多学习., beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzUn81b5CF5ibVPib8jWI92iciaxmqGHlwruOnK4SVZykd4iahqo1hicklIibyZoxm55X7EM8BW9eX1h1hQ2/0, createdBy=8aa81937526, createdName=李东泽, createdTime=Thu Sep 28 08:16:39 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248460, encodeId=275e24846059, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyhb9xDeHojCicsdRdyC3XXdGk2ib9yLypZuHN06WeW4HO8WN0GGrgEfvnTX8gsckof05GHOU5OM4Mvx/0, createdBy=9cee1982656, createdName=执着追梦, createdTime=Thu Sep 28 07:54:35 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=248459, encodeId=c07e24845958, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e7f41959343, createdName=1e131038m59(暂无匿称), createdTime=Thu Sep 28 07:51:32 CST 2017, time=2017-09-28, status=1, ipAttribution=)]
    2017-09-28 执着追梦

    学习.谢谢分享

    0

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    2017-09-28 1e131038m59(暂无匿称)

    学习了

    0

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