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目的研究创建糖尿病社区干预路径,提高社区对糖尿病等慢性非传染性疾病(简称慢病)的规范化干预水平。方法借鉴住院路径的模式,在糖尿病社区干预的时间长度和周期、动态监测指标的筛选、路径书版本设计等方面均有较大改变。结果医生们的干预工作每一步均有路径可循,患者版的路径书使患者全年度干预计划了解,能积极配合干预。结论糖尿病社区干预路径的研究与创建,对社区慢病干预工作起到了引领作用。
Objective To study ways to create a community intervention for diabetes and to improve the standardization of community intervention in chronic non-communicable diseases such as diabetes (referred to as chronic diseases). The method draws lessons from the patterns of inpatient pathways, which have great changes in the time and period of diabetes community intervention, the screening of dynamic monitoring indicators, the design of route books version and so on. Results The doctors’ interventions followed each step of the way. The patient version of the pathbook made the patient aware of the annual intervention plan and could actively cooperate with the intervention. Conclusion The research and creation of community intervention pathways in diabetes played a leading role in community chronic disease intervention.