患者信息管理 ：

　　Patient information management:

　　收集患者的基本信息，如姓名、年齡等。

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

　　獲取患者的疾病診療信息，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.

　　為患者建立健康檔案，并填寫相關管理表格。

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

　　隨訪評估 ：

　　Follow up evaluation:

　　定期對患者進行隨訪，頻率依據患者的具體情況而定。

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

　　隨訪內容包括患者的精神狀況、身體狀況、社會功能、用藥情況以及實驗室檢查結果等。

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

　　分類干預 ：

　　Classification intervention:

　　根據患者的評估分級、社會功能狀況、精神癥狀評估、自知力判斷以及藥物不良反應或軀體疾病情況，對患者實施分類干預。

　　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.

　　根據病情變化及時調整隨訪周期，并提供相應的健康教育和生活技能訓練。

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

　　具體隨訪活動 ：

　　Specific follow-up activities:

　　對于高血壓患者，定期測量血壓，并評估是否存在危急情況，如血壓過高或過低。

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

　　對于糖尿病患者，測量體重、血糖，并計算體質指數（BMI），檢查足背動脈搏動。

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

　　對于孕產婦，建立保健手冊，進行孕期檢查和產后訪視，提供母乳喂養、產后護理和疾病預防指導。

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

　　對于新生兒和嬰幼兒，進行定期的健康管理服務，包括喂養、睡眠、大小便、黃疸情況的觀察，以及體重、身長的測量和發育評估。

　　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.

　　記錄和報告 ：

　　Record and report:

　　記錄隨訪過程中的所有數據和發現，包括患者的反應和依從性。

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

　　如遇緊急情況，須立即處理并轉診。

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

　　在規定的時間內主動隨訪轉診情況。

　　Proactively follow up on referral status within the specified time.

　　以上步驟可能因地區和具體公共衛生政策而有所不同。請根據當地的具體規定和流程執行公共衛生隨訪

　　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

　　本文由公衛隨訪箱提供幫助，更多的相關內容請點擊：http://www.cdrtd.cn希望本文能夠為您帶來幫助，感謝您的閱讀！

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