糖尿病患者健康档案

高血压糖尿病患者管理档案填写张静蠡县疾病预防控制中心高血压、糖尿病人个人基本信息表若在年度体检或者随访时得知患者或者亲属经一级以上医院确诊了某种疾病，需要在既往史或者家族史处完善信息。

•个人基本信息表中既往史：高血压、糖尿病人健康体检表超重肥胖者应指导减重，制定减重目标，中心型肥胖应指导减腰围。

只要非每天，就要指导如何锻炼“根据健康，适量运动”健康指导必须建议转诊健康指导必须建议转诊糖尿病人必查包括在年度体检或者随访时得知患者经一级以上医院确诊的某种疾病应写高血压病现存主要健康问题，指曾经出现或一直存在，并影响目前身体健康状况的疾病。

高血压病、糖尿病填写在“其他系统疾病”栏内。

新发疾病需同期更新个人信息表的既往疾病史，两表内容统一。

健康评价危险因素控制高血压、糖尿病人随访记录表高血压随访表填写注意事项高血压随访表填写注意事项高血压患者血压控制满意标准：普通高血压患者血压降至140/90 mmHg以下；糖尿病、肾病患者血压降至140/90 mmHg以下；≥65岁高血压患者的血压降至150/90 mmHg以下；高血压随访表填写注意事项药品名称化学名称和商品名都要填写。

165/95恶心呕吐（转诊，填写双向转诊单）要写明转诊的医疗机构及科室类别如×市人民医院心内科，并写明原因。

糖尿病随访表填写注意事项糖尿病病人必查血糖控制满意的标准是<7.0mmol/L,若≥7.0mml/L 叫做血糖控制不满意，一次控制不满意2周内追加一次随访，连续两次控制不满意建议转诊，2周后随访转诊情况既是高血压患者又是糖尿病患者（简称“高糖患者”）两张随访表随访时间，血压，体重、体质指数等情况必须填写一致。

居民健康档案表单目录1.居民健康档案封面2.个人基本信息表3.健康体检表4.重点人群健康管理记录表（卡）（见各专项服务规范相关表单）4.1 0～6岁儿童健康管理记录表4.1.1 新生儿家庭访视记录表4.1.2 1岁以内儿童健康检查记录表4.1.3 1～2岁儿童健康检查记录表4.1.4 3～6岁儿童健康检查记录表4.2 孕产妇健康管理记录表4.2.1 第1次产前随访服务记录表4.2.2 第2～5次产前随访服务记录表4.2.3 产后访视记录表4.2.4 产后42天健康检查记录表4.3 预防接种卡4.4 高血压患者随访服务记录表4.5 2型糖尿病患者随访服务记录表4.6 重性精神疾病患者管理记录表4.6.1 重性精神疾病患者个人信息补充表4.6.2 重性精神疾病患者随访服务记录表5.其他医疗卫生服务记录表5.1 接诊记录表5.2 会诊记录表6.居民健康档案信息卡一、老年人、高血压与糖尿病患者健康档案的（形式）内容同居民健康档案（包括档案的封面），每人一个档案，一名患者同时有多种身份，即同时是居民、老年人、高血压与糖尿病患者只建立一个档案即可，除了封面与个人基本情况表外，其他表格只有开展并填写后才放在健康档案里。

二、内容包括以下几项：1.健康档案封面：（居民、老年人、高血压与糖尿病等特殊人群均统一使用同一封面）2个人基本情况表：（居民、老年人、高血压与糖尿病等特殊人群均统一使用同一个人情况表）包括姓名、性别等基础信息和既往史、家族史等基本健康信息。

3.健康体检表：（居民、老年人、高血压与糖尿病等特殊人群均统一使用同一个健康体检表）包括一般健康检查、生活方式、健康状况及其疾病用药情况、健康评价等。

4、重点人群健康管理记录表：老年人要有《老年人生活要有自理能力评估表》，高血压患者要有《高血压患者随访记录表》，糖尿病患者要有《糖尿病患者随访记录表》。

5.其他医疗卫生服务记录表：其他接诊、转诊、会诊记录等，如有开展，由相关临床医生填写后放到健康档案里。

糖尿病居民健康档案范文英文回答：Diabetes is a chronic condition that affects millionsof people worldwide. As a healthcare professional, it is important to maintain comprehensive health records for diabetic residents. These health records serve as avaluable resource for monitoring and managing their condition.Firstly, the health records should include the basic information of the diabetic resident, such as their name, age, gender, and contact details. This helps in identifying the individual and ensuring accurate communication. Additionally, it is crucial to record their medical history, including any previous diagnoses, treatments, and surgeries. This information provides insights into the resident'shealth journey and helps in understanding their current condition.Furthermore, it is essential to document the resident's current symptoms and complaints. For instance, if adiabetic resident is experiencing frequent urination, excessive thirst, and unexplained weight loss, these symptoms should be recorded in detail. This informationaids in identifying potential complications and determining appropriate treatment plans.In addition to symptoms, it is important to track the resident's blood glucose levels regularly. This can be done by recording the results of their blood glucose tests, including fasting blood sugar levels, postprandial levels, and HbA1c levels. These measurements help in assessing the effectiveness of the resident's diabetes management planand adjusting it if necessary.Moreover, it is crucial to document the resident's current medications and dosages. This includes both oral medications and insulin injections. It is important to record the type of medication, dosage, frequency, and any potential side effects. This information helps in ensuring proper medication management and avoiding drug interactions.Furthermore, it is beneficial to include dietary information in the health records. This includes theresident's current dietary plan, any specific dietary restrictions, and their adherence to the plan. For example, if a diabetic resident is following a low-carbohydrate diet, it should be documented along with their compliance to the diet. This information assists in evaluating the impact of diet on blood glucose control.Additionally, it is important to document theresident's physical activity level. Regular exercise playsa vital role in diabetes management. Therefore, it is necessary to record the type of exercise, duration, and frequency. This information helps in assessing theresident's overall lifestyle and determining the effectiveness of their exercise regimen.Lastly, it is crucial to document any diabetic complications or comorbidities. For example, if a diabetic resident has developed diabetic retinopathy or cardiovascular disease, it should be recorded in the healthrecords. This information aids in understanding theresident's overall health status and allows for appropriate interventions and referrals.In conclusion, maintaining comprehensive health records for diabetic residents is essential for effective diabetes management. These records should include basic information, medical history, symptoms, blood glucose levels, medications, dietary information, physical activity level, and any complications or comorbidities. By documentingthese details, healthcare professionals can provide personalized care and monitor the resident's progress effectively.中文回答：糖尿病是一种慢性疾病，影响着全球数百万人。

护理糖尿病病案护理记录单
病人基本信息：姓名XXX，性别男，年龄60岁，职业工程师。

入院日期：XXX年XX月XX日
主诉：多尿、口渴、体重下降，担心是糖尿病。

病史：患有高血压10年，有吸烟史，家族中有糖尿病史。

查体：体温36.5℃，血压140/90mmHg，心率80次/分，呼吸
20次/分，血糖12.5mmol/L。

诊断：糖尿病2型。

护理措施：
1. 督促患者按医嘱规律服药，保持血糖稳定。

2. 每日监测患者血糖、血压、体温等生命体征，随时密切观察病情变化。

3. 指导患者合理饮食，低糖低脂饮食原则，避免高糖高脂食物。

4. 协助患者进行锻炼，控制体重，提高胰岛素敏感性。

5. 营造良好的护理环境，保持病房整洁，避免感染。

预后：病情稳定好转，患者情绪稳定，有良好的配合意识。

计划出院后继续规范用药，定期复查，注意饮食调节和锻炼。