嚴重精神障礙患者管理服務規范

一、服務對象

轄區內常住居民中診斷明確、在家居住的嚴重精神障礙患者。主要包括精神分裂癥、分裂情感性障礙、偏執性精神病、雙相情感障礙、癲癇所致精神障礙、精神發育遲滯伴發精神障礙。

二、服務內容

(一)患者信息管理

在將嚴重精神障礙患者納入管理時,需由家屬提供或直接轉自原承擔治療任務的專業醫療衛生機構的疾病診療相關信息,同時為患者進行一次全面評估,為其建立居民健康檔案,并按照要求填寫嚴重精神障礙患者個人信息補充表。

(二)隨訪評估

對應管理的嚴重精神障礙患者每年至少隨訪4次,每次隨訪應對患者進行危險性評估;檢查患者的精神狀況,包括感覺、知覺、思維、情感和意志行為、自知力等;詢問和評估患者的軀體疾病、社會功能情況、用藥情況及各項實驗室檢查結果等。其中,危險性評估分為6級。

0級:無符合以下1-5級中的任何行為。

1級:口頭威脅,喊叫,但沒有打砸行為。

2級:打砸行為,局限在家里,針對財物,能被勸說制止。

3級:明顯打砸行為,不分場合,針對財物,不能接受勸說而停止。

4級:持續的打砸行為,不分場合,針對財物或人,不能接受勸說而停止(包括自傷、自殺)。

5級:持械針對人的任何暴力行為,或者縱火、爆炸等行為,無論在家里還是公共場合。

(三)分類干預

根據患者的危險性評估分級、社會功能狀況、精神癥狀評估、自知力判斷,以及患者是否存在藥物不良反應或軀體疾病情況對患者進行分類干預。

1.病情不穩定患者。若危險性為3~5級或精神癥狀明顯、自知力缺乏、有嚴重藥物不良反應或嚴重軀體疾病,對癥處理后立即轉診到上級醫院。必要時報告當地公安部門,2周內了解其治療情況。對于未能住院或轉診的患者,聯系精神專科醫師進行相應處置,并在居委會人員、民警的共同協助下,2周內隨訪。

2.病情基本穩定患者。若危險性為1~2級,或精神癥狀、自知力、社會功能狀況至少有一方面較差,首先應判斷是病情波動或藥物療效不佳,還是伴有藥物不良反應或軀體癥狀惡化,分別采取在規定劑量范圍內調整現用藥物劑量和查找原因對癥治療的措施,2周時隨訪,若處理后病情趨于穩定者,可維持目前治療方案,3個月時隨訪;未達到穩定者,應請精神專科醫師進行技術指導,1個月時隨訪。

3.病情穩定患者。若危險性為0級,且精神癥狀基本消失,自知力基本恢復,社會功能處于一般或良好,無嚴重藥物不良反應,軀體疾病穩定,無其他異常,繼續執行上級醫院制定的治療方案,3個月時隨訪。

4.每次隨訪根據患者病情的控制情況,對患者及其家屬進行有針對性的健康教育和生活技能訓練等方面的康復指導,對家屬提供心理支持和幫助。

(四)健康體檢

在患者病情許可的情況下,征得監護人與(或)患者本人同意后,每年進行1次健康檢查,可與隨訪相結合。內容包括一般體格檢查、血壓、體重、血常規(含白細胞分類)、轉氨酶、血糖、心電圖。

三、服務流程

四、服務要求

(一)配備接受過嚴重精神障礙管理培訓的專(兼)職人員,開展本規范規定的健康管理工作。

(二)與相關部門加強聯系,及時為轄區內新發現的嚴重精神障礙患者建立健康檔案并根據情況及時更新。

(三)隨訪包括預約患者到門診就診、電話追蹤和家庭訪視等方式。

(四)加強宣傳,鼓勵和幫助患者進行社會功能康復訓練,指導患者參與社會活動,接受職業訓練。

五、工作指標

嚴重精神障礙患者規范管理率=年內轄區內按照規范要求進行管理的嚴重精神障礙患者人數/年內轄區內登記在冊的確診嚴重精神障礙患者人數×100%。

附件:
            嚴重精神障礙患者個人信息補充表.docx
            嚴重精神障礙患者隨訪服務記錄表.docx
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