患者信息管理 ：

　　Patient information management:

　　收集患者的基本信息，如姓名、年龄等。

　　Collect basic information of patients, such as name, age, etc.

　　获取患者的疾病诊疗信息，包括既往病史和家族病史。

　　Obtain the patient's disease diagnosis and treatment information, including past medical history and family medical history.

　　为患者建立健康档案，并填写相关管理表格。

　　Establish health records for patients and fill out relevant management forms.

　　随访评估 ：

　　Follow up evaluation:

　　定期对患者进行随访，频率依据患者的具体情况而定。

　　Regularly follow up with patients, with the frequency depending on their specific condition.

　　随访内容包括患者的精神状况、身体状况、社会功能、用药情况以及实验室检查结果等。

　　The follow-up content includes the patient's mental condition, physical condition, social function, medication use, and laboratory test results.

　　分类干预 ：

　　Classification intervention:

　　根据患者的评估分级、社会功能状况、精神症状评估、自知力判断以及药物不良反应或躯体疾病情况，对患者实施分类干预。

　　Based on the patient's evaluation grading, social function status, psychiatric symptom assessment, self-awareness judgment, as well as adverse drug reactions or physical disease conditions, classified interventions are implemented for the patient.

　　根据病情变化及时调整随访周期，并提供相应的健康教育和生活技能训练。

　　Adjust the follow-up period in a timely manner according to changes in the condition, and provide corresponding health education and life skills training.

　　具体随访活动 ：

　　Specific follow-up activities:

　　对于高血压患者，定期测量血压，并评估是否存在危急情况，如血压过高或过低。

　　For patients with hypertension, regularly measure blood pressure and assess whether there is a critical condition, such as high or low blood pressure.

　　对于糖尿病患者，测量体重、血糖，并计算体质指数（BMI），检查足背动脉搏动。

　　For patients with diabetes, measure weight, blood sugar, calculate body mass index (BMI), and check the pulse of dorsalis pedis artery.

　　对于孕产妇，建立保健手册，进行孕期检查和产后访视，提供母乳喂养、产后护理和疾病预防指导。

　　For pregnant women, establish a health manual, conduct prenatal check ups and postpartum visits, provide guidance on breastfeeding, postpartum care, and disease prevention.

　　对于新生儿和婴幼儿，进行定期的健康管理服务，包括喂养、睡眠、大小便、黄疸情况的观察，以及体重、身长的测量和发育评估。

　　For newborns and infants, regular health management services should be provided, including feeding, sleep, observation of urination and defecation, jaundice, as well as measurement and developmental assessment of weight and length.

　　记录和报告 ：

　　Record and report:

　　记录随访过程中的所有数据和发现，包括患者的反应和依从性。

　　Record all data and findings during the follow-up process, including patient responses and compliance.

　　如遇紧急情况，须立即处理并转诊。

　　In case of emergency, immediate handling and referral are required.

　　在规定的时间内主动随访转诊情况。

　　Proactively follow up on referral status within the specified time.

　　以上步骤可能因地区和具体公共卫生政策而有所不同。请根据当地的具体规定和流程执行公共卫生随访

　　The above steps may vary depending on the region and specific public health policies. Please follow up on public health according to specific local regulations and procedures

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　　This article is assisted by the Public Health Follow up Box. For more related content, please click: http://www.yixiangyiliao.com I hope this article can be helpful to you. Thank you for reading!