电子健康档案管理：通过数字化手段收集、存储和共享患者的健康信息，便于医生监测病情变化。利用信息系统记录并追踪患者的基本资料、既往病史及用药情况等，以便及时调整治疗方案。

　　Electronic Health Record Management: Collecting, storing, and sharing patients' health information through digital means to facilitate doctors in monitoring changes in their condition. Utilize information systems to record and track patients' basic information, medical history, medication use, etc., in order to adjust treatment plans in a timely manner.

　　定期面对面评估：通过与患者直接交流，了解其心理状态及行为模式，有助于早期发现异常信号。安排固定时间进行面对面访谈，确保信息准确性和完整性。

　　Regular face-to-face assessment: By directly communicating with patients, understanding their psychological state and behavioral patterns can help detect abnormal signals early. Schedule a fixed time for face-to-face interviews to ensure accuracy and completeness of information.

　　社区支持网络：构建互助小组或联系当地心理健康组织，为患者创造一个安全且有归属感的环境。鼓励患者参与集体活动以促进人际交往，并接受来自同侪群体的理解与帮助。

　　Community support network: Build mutual aid groups or contact local mental health organizations to create a safe and belonging environment for patients. Encourage patients to participate in group activities to promote interpersonal communication and accept understanding and help from peer groups.

　　家庭访视教育：由专业人员对家属进行培训，使其掌握识别早期症状和应对策略。定期上门开展讲座或个别指导，提高家人识别风险因素的能力。

　　Family visit education: Professional personnel provide training to family members to enable them to identify early symptoms and coping strategies. Regularly conduct on-site lectures or individual guidance to enhance family members' ability to identify risk factors.

　　药物治疗管理：跟踪服药情况，确保按时按量服用处方药物，监控可能影响患者依从性的因素，并采取相应措施改善。

　　Drug therapy management: track medication status, ensure timely and adequate use of prescribed drugs, monitor factors that may affect patient compliance, and take corresponding measures to improve.

　　入户随访：医务人员携带血压计、血糖仪及健康宣传册，对社区居民进行逐户上门随访。详细询问患者的健康情况、生活习惯、饮食、服药情况，进行健康评估，并指导慢性病患者正确服药，保持合理膳食、适量运动、戒烟限酒、良好的心态和健康的生活方式。

　　Household follow-up: Medical staff carry blood pressure monitors, blood glucose meters, and health brochures to conduct door-to-door follow-up visits to community residents. Inquire in detail about the patient's health status, lifestyle habits, diet, and medication status, conduct a health assessment, and guide chronic disease patients to take medication correctly, maintain a reasonable diet, moderate exercise, quit smoking and limit alcohol consumption, maintain a good mentality, and adopt a healthy lifestyle.

　　电话或微信随访：通过电话、微信等方式定期了解患者病情变化和指导患者康复。近期随访主要观察患者治疗的效果及用药反应，根据随访情况和复查结果来调整用药；远期随访可以获得患者治疗方案的长期效果、远期并发症，有利于筛选出更有效的治疗方法。

　　Telephone or WeChat follow-up: Regularly monitor changes in the patient's condition and guide their recovery through telephone, WeChat, and other means. The recent follow-up mainly observes the treatment effect and medication response of patients, and adjusts medication according to the follow-up situation and re examination results; Long term follow-up can obtain the long-term effects and complications of the patient's treatment plan, which is beneficial for screening more effective treatment methods.

　　健康教育服务：提供健康教育资料、设置健康教育宣传栏、开展公众健康咨询活动、举办健康知识讲座、开展个体化健康教育等，提高居民的健康意识和自我管理能力。

　　Health education services: providing health education materials, setting up health education bulletin boards, conducting public health consultation activities, holding health knowledge lectures, conducting personalized health education, etc., to enhance residents' health awareness and self-management ability.

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