家签随访包记录是家庭医生签约服务中，记录患者健康状况、干预措施及随访结果的重要文书，既是医患沟通的凭证，也是连续健康管理的依据。其撰写需遵循客观、准确、完整的原则，清晰反映随访全过程，同时兼顾实用性与规范性，为后续诊疗和健康评估提供可靠参考。

　　The home follow-up package record is an important document in the family doctor contract service, which records the patient's health status, intervention measures, and follow-up results. It is not only a voucher for doctor-patient communication, but also a basis for continuous health management. Its writing should follow the principles of objectivity, accuracy, and completeness, clearly reflect the entire follow-up process, and balance practicality and standardization, providing reliable references for subsequent diagnosis, treatment, and health assessment.

　　记录的基本要素需全面涵盖，确保信息完整无遗漏。开头应明确随访对象的基础信息：姓名、性别、年龄、家庭住址、签约医生姓名及随访日期，若为慢性病患者需注明病种（如高血压 2 级、2 型糖尿病）及病程年限。核心内容包括随访原因（如常规履约随访、患者主动求助、指标异常复查）、当前健康状况（如 “血压 145/90mmHg，较上次升高 5mmHg”“空腹血糖 7.8mmol/L，自述近期饮食未控制”），需具体描述患者的症状（如 “近 3 天偶有头晕”）、体征（如 “心率 85 次 / 分，律齐”）及生活习惯（如 “每日吸烟 10 支，未戒酒”）。干预措施部分要详细记录医嘱内容：用药调整（如 “硝苯地平缓释片由 10mg / 日增至 20mg / 日”）、检查建议（如 “建议本周内完成血脂四项检测”）、生活方式指导（如 “每日食盐摄入量控制在 5g 以内，每周运动 3 次，每次 30 分钟”），需注明患者对建议的接受程度（如 “患者表示理解，愿意尝试减少吸烟量”）。

　　The basic elements of recording need to be comprehensively covered to ensure complete information without omission. At the beginning, the basic information of the follow-up object should be clear: name, gender, age, home address, name of the contracted doctor and follow-up date. If the patient is a chronic disease, the disease type (such as hypertension grade 2, type 2 diabetes) and duration of the disease should be indicated. The core content includes the reasons for follow-up (such as routine performance follow-up, patient initiated seeking help, abnormal index re examination), current health status (such as "blood pressure 145/90mmHg, increased by 5mmHg compared to last time", "fasting blood glucose 7.8mmol/L, self-reported recent uncontrolled diet"), specific description of the patient's symptoms (such as "occasional dizziness in the past 3 days"), physical signs (such as "heart rate 85 beats per minute, regular rhythm"), and lifestyle habits (such as "smoking 10 cigarettes a day, not quitting drinking"). The intervention measures section should record in detail the contents of medical orders: medication adjustments (such as "nifedipine sustained-release tablets from 10mg/day to 20mg/day"), examination recommendations (such as "it is recommended to complete four blood lipid tests within this week"), lifestyle guidance (such as "daily salt intake should be controlled within 5g, exercise 3 times a week for 30 minutes each time"), and indicate the patient's acceptance of the recommendations (such as "the patient expresses understanding and willingness to try reducing smoking").

　　撰写规范需注重专业性与可读性的平衡，避免模糊表述。数据记录要精确到具体数值，禁用 “血压偏高”“血糖还好” 等模糊描述，需写明测量时间（如 “晨间 7 点未服药时测量”）、测量工具（如 “电子血压计”“家用血糖仪”）及环境条件（如 “患者休息 10 分钟后测量”）。症状描述需包含发生时间、频率及伴随情况，如 “夜间阵发性呼吸困难，每周发作 2-3 次，坐起后缓解” 比 “呼吸困难” 更具临床价值。用药记录需完整，包括药品名称、规格、剂量、用法及频次（如 “阿司匹林肠溶片 100mg 每日 1 次 口服”），若患者存在漏服、自行停药等情况，需注明原因（如 “因胃部不适，近 3 天未服阿司匹林”）。记录结尾需明确下次随访计划：时间（如 “2 周后复查血压”）、重点关注内容（如 “监测调整用药后的血压变化”）及患者需准备的事项（如 “记录每日血压测量值，就诊时携带”）。

　　Writing standards should pay attention to the balance between professionalism and readability, and avoid vague expressions. Data recording should be accurate to specific values, and vague descriptions such as "high blood pressure" and "good blood sugar" should be avoided. The measurement time (such as "measured when not taking medication at 7am in the morning"), measurement tools (such as "electronic blood pressure monitor" and "home blood glucose meter"), and environmental conditions (such as "measured after the patient rests for 10 minutes") should be clearly stated. The symptom description should include the occurrence time, frequency, and accompanying conditions, such as "paroxysmal dyspnea at night, 2-3 episodes per week, relieved after sitting up" which is more clinically valuable than "dyspnea". The medication record should be complete, including the drug name, specifications, dosage, usage, and frequency (such as "Aspirin enteric coated tablets 100mg once daily orally"). If the patient has missed or stopped taking the medication on their own, the reason should be indicated (such as "not taking aspirin in the past 3 days due to stomach discomfort"). At the end of the record, it is necessary to clarify the next follow-up plan: time (such as "blood pressure recheck in 2 weeks"), key focus areas (such as "monitoring and adjusting blood pressure changes after medication"), and items that the patient needs to prepare (such as "recording daily blood pressure measurements and bringing them to the clinic").

　　不同场景的记录需突出重点，体现个性化健康管理。慢性病患者随访记录应侧重指标变化与干预效果，如高血压患者需对比近 3 次血压值，分析波动原因（如 “血压升高与上周未规律服药相关”）；糖尿病患者需记录血糖与饮食、运动的关联（如 “餐后血糖升高与昨日食用 2 个馒头有关”）。康复期患者记录要聚焦功能恢复进度，如中风后遗症患者需描述肢体活动能力变化（如 “左上肢可自主抬至胸前，较上次提升 10cm”）、康复训练完成情况（如 “每日完成手部抓握训练 3 组，每组 10 次”）。老年独居患者记录需包含安全风险评估，如 “家中地面湿滑，已建议铺设防滑垫”“一键呼叫设备电量充足，可正常使用”，同时记录社会支持情况（如 “子女每周探望 1 次，可协助监督用药”）。

　　The recording of different scenarios should highlight key points and reflect personalized health management. Follow up records of chronic disease patients should focus on changes in indicators and intervention effects. For example, hypertensive patients need to compare their blood pressure values in the past three times and analyze the reasons for fluctuations (such as "blood pressure elevation is related to irregular medication last week"); Diabetes patients need to record the relationship between blood sugar and diet, exercise (such as "the increase of blood sugar after meals is related to the consumption of two Mantou yesterday"). During the rehabilitation period, patient records should focus on the progress of functional recovery. For example, patients with post-stroke sequelae need to describe changes in their physical activity ability (such as "the left upper limb can be lifted to the chest independently, an increase of 10cm compared to the last time"), and the completion of rehabilitation training (such as "completing 3 sets of hand grasping training per day, 10 times per set"). The records of elderly patients living alone should include a safety risk assessment, such as "the floor at home is wet and slippery, and it has been recommended to install anti-skid mats", "the one click call device has sufficient battery and can be used normally", and also record social support (such as "children visit once a week and can assist in monitoring medication").

　　记录的语言风格需简洁明了，避免专业术语堆砌，让患者及家属能清晰理解。对患者的表述可适当引用原话（加引号标注），如患者说 “吃了药后头晕减轻了”，记录时可写成 “自述服药后头晕症状缓解”。避免使用否定性、刺激性语言，如不说 “患者拒绝戒烟，态度恶劣”，而表述为 “患者暂未接受戒烟建议，计划下次随访时进一步沟通”。对于需要向其他医疗机构转诊的情况，记录需注明转诊原因（如 “血压持续升高，药物调整后仍未达标”）、转诊机构及初步诊断（如 “转诊至 XX 医院心内科，初步考虑为难治性高血压”），便于后续机构了解病情延续性。

　　The language style of recording should be concise and clear, avoiding the accumulation of professional terminology, so that patients and their families can understand clearly. The patient's statement can be appropriately quoted (with quotation marks), for example, if the patient says "dizziness has improved after taking the medicine", the record can be written as "self-reported relief of dizziness symptoms after taking the medicine". Avoid using negative or provocative language, such as not saying 'the patient refuses to quit smoking and has a bad attitude', but stating 'the patient has not yet accepted the smoking cessation advice and plans to further communicate during the next follow-up'. For situations that require referral to other medical institutions, the record should indicate the reason for the referral (such as "continuous increase in blood pressure, medication adjustment still not meeting the standard"), the referral institution, and preliminary diagnosis (such as "referral to the cardiology department of XX hospital, preliminary consideration of refractory hypertension"), in order to understand the continuity of the condition in subsequent institutions.

　　记录的管理与归档需符合规范，确保可追溯性。每次随访后应及时完成记录（建议 24 小时内），避免记忆模糊导致信息偏差。记录需手写签名（签约医生）及患者（或家属）确认签名，电子记录需按规定加密保存，保护患者隐私。定期对记录进行梳理分析，总结患者健康变化趋势（如 “近 3 个月血压控制达标率逐步提升，从 60% 升至 85%”），为调整健康管理方案提供依据。对于异常情况（如指标骤变、严重不良反应），需在记录中标注 “重点关注”，并及时上报相关负责人，启动干预机制。

　　The management and archiving of records must comply with regulations to ensure traceability. After each follow-up visit, records should be completed promptly (within 24 hours is recommended) to avoid information bias caused by memory blur. The record requires handwritten signature (signed by the contracted doctor) and confirmation signature from the patient (or family member). Electronic records must be encrypted and stored according to regulations to protect patient privacy. Regularly review and analyze records, summarize the trend of patient health changes (such as "the blood pressure control compliance rate has gradually increased from 60% to 85% in the past 3 months"), and provide a basis for adjusting health management plans. For abnormal situations (such as sudden changes in indicators or serious adverse reactions), it is necessary to mark "key concerns" in the records and promptly report to the relevant person in charge to initiate intervention mechanisms.

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