老年人健康管理服務規范

一、服務對象

轄區內65歲及以上常住居民。

二、服務內容

每年為老年人提供1次健康管理服務,包括生活方式和健康狀況評估、體格檢查、輔助檢查和健康指導。

(一)生活方式和健康狀況評估。通過問診及老年人健康狀態自評了解其基本健康狀況、體育鍛煉、飲食、吸煙、飲酒、慢性疾病常見癥狀、既往所患疾病、治療及目前用藥和生活自理能力等情況。

(二)體格檢查。包括體溫、脈搏、呼吸、血壓、身高、體重、腰圍、皮膚、淺表淋巴結、肺部、心臟、腹部等常規體格檢查,并對口腔、視力、聽力和運動功能等進行粗測判斷。

(三)輔助檢查。包括血常規、尿常規、肝功能(血清谷草轉氨酶、血清谷丙轉氨酶和總膽紅素)、腎功能(血清肌酐和血尿素)、空腹血糖、血脂(總膽固醇、甘油三酯、低密度脂蛋白膽固醇、高密度脂蛋白膽固醇)、心電圖和腹部B超(肝膽胰脾)檢查。

(四)健康指導。告知評價結果并進行相應健康指導。

1.對發現已確診的原發性高血壓和2型糖尿病等患者同時開展相應的慢性病患者健康管理。

2.對患有其他疾病的(非高血壓或糖尿病),應及時治療或轉診。

3.對發現有異常的老年人建議定期復查或向上級醫療機構轉診。

4.進行健康生活方式以及疫苗接種、骨質疏松預防、防跌倒措施、意外傷害預防和自救、認知和情感等健康指導。

5.告知或預約下一次健康管理服務的時間。

三、服務流程

四、服務要求

(一)開展老年人健康管理服務的鄉鎮衛生院和社區衛生服務中心應當具備服務內容所需的基本設備和條件。

(二)加強與村(居)委會、派出所等相關部門的聯系,掌握轄區內老年人口信息變化。加強宣傳,告知服務內容,使更多的老年人愿意接受服務。

(三)每次健康檢查后及時將相關信息記入健康檔案。具體內容詳見《居民健康檔案管理服務規范》健康體檢表。對于已納入相應慢病健康管理的老年人,本次健康管理服務可作為一次隨訪服務。

(四)積極應用中醫藥方法為老年人提供養生保健、疾病防治等健康指導。

五、工作指標

老年人健康管理率=年內接受健康管理人數/年內轄區內65歲及以上常住居民數×100%。

注:接受健康管理是指建立了健康檔案、接受了健康體檢、健康指導、健康體檢表填寫完整。

附件:
            老年人生活自理能力評估表.docx
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