慢性病患者随访​

Follow up of chronic disease patients

慢性病患者需要长期、持续的健康管理。公卫随访人员携带随访包，定期上门为高血压、糖尿病患者测量血压、血糖，了解病情控制情况，指导患者正确用药，并根据检查结果调整治疗方案。通过面对面交流，工作人员还能向患者传授健康饮食、适量运动等方面的知识，增强患者的自我管理意识，提高疾病控制效果。​

Chronic disease patients require long-term and continuous health management. The public health follow-up personnel carry the follow-up bag, regularly come to the door to measure blood pressure and blood sugar for patients with hypertension and diabetes, understand the condition control, guide patients to use drugs correctly, and adjust the treatment plan according to the inspection results. Through face-to-face communication, staff can also impart knowledge on healthy eating and moderate exercise to patients, enhance their self-management awareness, and improve disease control effectiveness. ​

孕产妇和儿童健康管理​

Maternal and Child Health Management

对于孕产妇，随访人员在不同孕期上门进行检查，使用随访包中的设备测量孕妇的血压、体重，听胎心，了解孕期身体状况，给予孕期保健指导。产后，还会对产妇和新生儿进行访视，检查新生儿的身体发育情况，指导产妇进行母乳喂养和产后康复。在儿童健康管理方面，工作人员通过定期测量儿童的身高、体重，进行生长发育评估，及时发现生长发育异常，为儿童健康成长保驾护航。​

For pregnant women, follow-up personnel visit their homes at different stages of pregnancy for examinations. They use the equipment in the follow-up package to measure the pregnant woman's blood pressure and weight, listen to fetal heart rate, understand the physical condition during pregnancy, and provide guidance on prenatal care. After childbirth, we will also visit the mother and newborn to check their physical development and guide them in breastfeeding and postpartum recovery. In terms of children's health management, staff regularly measure children's height and weight, conduct growth and development assessments, and promptly detect abnormal growth and development, providing protection for children's healthy growth. ​

传染病防控随访​

Follow up on infectious disease prevention and control

在传染病防控工作中，公卫随访包同样发挥着重要作用。随访人员对传染病患者或密切接触者进行追踪随访，测量体温，了解症状变化，及时发现病情进展，为疫情防控提供依据。同时，向患者和密切接触者宣传传染病防控知识，指导其做好个人防护和隔离措施，防止疫情传播。​

In the prevention and control of infectious diseases, the public health follow-up package also plays an important role. Follow up personnel track and follow up infectious disease patients or close contacts, measure body temperature, understand symptom changes, timely detect disease progression, and provide a basis for epidemic prevention and control. At the same time, promote infectious disease prevention and control knowledge to patients and close contacts, guide them to take personal protective and isolation measures, and prevent the spread of the epidemic. ​

三、规范使用：发挥随访包最大效能​

3、 Standardized use: maximize the effectiveness of follow-up packages

准备阶段​

Preparation stage

在开展随访工作前，工作人员要对公卫随访包进行全面检查，确保设备功能正常、耗材充足。同时，了解随访对象的基本信息，制定个性化的随访计划，明确随访目的和重点内容。​

Before conducting follow-up work, staff should conduct a comprehensive inspection of the public health follow-up package to ensure that the equipment is functioning properly and consumables are sufficient. At the same time, understand the basic information of the follow-up subjects, develop personalized follow-up plans, clarify follow-up purposes and key content. ​

现场随访​

On site follow-up

到达随访现场后，工作人员要先向随访对象说明来意，取得对方的配合。按照规范操作流程，使用随访包中的设备进行各项检查，认真记录检查结果。在交流过程中，耐心倾听随访对象的诉求，解答他们的健康疑问，发放健康宣传资料，引导其养成健康的生活方式。​

After arriving at the follow-up site, the staff should first explain the purpose of the visit to the follow-up object and obtain their cooperation. According to the standard operating procedures, use the equipment in the follow-up package for various inspections and carefully record the inspection results. During the communication process, patiently listen to the demands of the follow-up subjects, answer their health questions, distribute health promotion materials, and guide them to develop a healthy lifestyle. ​

随访后工作​

Follow up work

随访结束后，工作人员要及时对随访数据进行整理和分析，将检查结果录入公共卫生管理系统，为后续的健康管理提供数据支持。对发现的健康问题，及时进行反馈和处理，必要时安排转诊治疗。同时，对公卫随访包进行清洁和消毒，补充耗材，为下一次随访做好准备。​​

After the follow-up is completed, the staff should promptly organize and analyze the follow-up data, enter the examination results into the public health management system, and provide data support for subsequent health management. Promptly provide feedback and handle any health issues discovered, and arrange for referral for treatment if necessary. At the same time, clean and disinfect the public health follow-up package, replenish consumables, and prepare for the next follow-up. ​​

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