肺結核患者健康管理服務規范

一、服務對象

轄區內確診的常住肺結核患者。

二、服務內容

(一)篩查及推介轉診

對轄區內前來就診的居民或患者,如發現有慢性咳嗽、咳痰≥2周,咯血、血痰,或發熱、盜汗、胸痛或不明原因消瘦等肺結核可疑癥狀者,在鑒別診斷的基礎上填寫“雙向轉診單”。推薦其到結核病定點醫療機構進行結核病檢查。1周內進行電話隨訪,了解是否前去就診,督促其及時就醫。

(二)第一次入戶隨訪

鄉鎮衛生院、村衛生室、社區衛生服務中心(站)接到上級專業機構管理肺結核患者的通知單后,要在72小時內訪視患者,具體內容如下:

(1)確定督導人員,督導人員優先為醫務人員,也可為患者家屬。若選擇家屬,則必須對家屬進行培訓。同時與患者確定服藥地點和服藥時間。按照化療方案,告知督導人員患者的“肺結核患者治療記錄卡”或“耐多藥肺結核患者服藥卡”的填寫方法、取藥的時間和地點,提醒患者按時取藥和復診。

(2)對患者的居住環境進行評估,告訴患者及家屬做好防護工作,防止傳染。

(3)對患者及家屬進行結核病防治知識宣傳教育。

(4)告訴患者出現病情加重、嚴重不良反應、并發癥等異常情況時,要及時就診。

若72小時內2次訪視均未見到患者,則將訪視結果向上級專業機構報告。

(三)督導服藥和隨訪管理

1. 督導服藥

(1)醫務人員督導:患者服藥日,醫務人員對患者進行直接面視下督導服藥。

(2)家庭成員督導:患者每次服藥要在家屬的面視下進行。

2. 隨訪評估

對于由醫務人員督導的患者,醫務人員至少每月記錄1次對患者的隨訪評估結果;對于由家庭成員督導的患者,基層醫療衛生機構要在患者的強化期或注射期內每10天隨訪1次,繼續期或非注射期內每1個月隨訪1次。

(1)評估是否存在危急情況,如有則緊急轉診,2周內主動隨訪轉診情況。

(2)對無需緊急轉診的,了解患者服藥情況(包括服藥是否規律,是否有不良反應),詢問上次隨訪至此次隨訪期間的癥狀。詢問其他疾病狀況、用藥史和生活方式。

3.分類干預

(1)對于能夠按時服藥,無不良反應的患者,則繼續督導服藥,并預約下一次隨訪時間。

(2)患者未按定點醫療機構的醫囑服藥,要查明原因。若是不良反應引起的,則轉診;若其他原因,則要對患者強化健康教育。若患者漏服藥次數超過1周及以上,要及時向上級專業機構進行報告。

(3)對出現藥物不良反應、并發癥或合并癥的患者,要立即轉診,2周內隨訪。

(4)提醒并督促患者按時到定點醫療機構進行復診。

(四)結案評估

當患者停止抗結核治療后,要對其進行結案評估,包括:記錄患者停止治療的時間及原因;對其全程服藥管理情況進行評估;收集和上報患者的“肺結核患者治療記錄卡”或“耐多藥肺結核患者服藥卡”。同時將患者轉診至結核病定點醫療機構進行治療轉歸評估,2周內進行電話隨訪,了解是否前去就診及確診結果。

三、服務流程

                                                    圖1 肺結核患者篩查與推介轉診流程圖

                                                     圖2 肺結核患者第一次入戶隨訪流程圖

                                                        圖3 肺結核患者督導服藥與隨訪管理流程圖

四、服務要求

(一)在農村地區,主要由村醫開展肺結核患者的健康管理服務。

(二)肺結核患者健康管理醫務人員需接受上級專業機構的培訓和技術指導。

(三)患者服藥后,督導人員按上級專業機構的要求,在患者服完藥后在“肺結核患者治療記錄卡”/“耐多藥肺結核患者服藥卡”中記錄服藥情況。患者完成療程后,要將“肺結核患者治療記錄卡”/“耐多藥肺結核患者服藥卡”交上級專業機構留存。

(四)提供服務后及時將相關信息記入“肺結核患者隨訪服務記錄表”,每月記入1次,存入患者的健康檔案,并將該信息與上級專業機構共享。

(五)管理期間如發現患者從本轄區居住地遷出,要及時向上級專業機構報告。

五、工作指標

(一)肺結核患者管理率=已管理的肺結核患者人數/轄區同期內經上級定點醫療機構確診并通知基層醫療衛生機構管理的肺結核患者人數×100%。

(二)肺結核患者規則服藥率=按照要求規則服藥的肺結核患者人數/同期轄區內已完成治療的肺結核患者人數×100%。

規則服藥:在整個療程中,患者在規定的服藥時間實際服藥次數占應服藥次數的90%以上。

附件:
            肺結核患者隨訪服務記錄表.docx
            肺結核患者第一次入戶隨訪記錄表.docx
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