PCU Manual Intregated Care

8/12/2019 PCU Manual Intregated Care

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:

:

11000 0 2590 1637-8 0 2590 1631http://www.203.157.3.100 ()

1 : 2546

: 12,000

:

36

ISBN 974-465-274-8


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( 2545-2546)

/ 6

9

2546


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1 11) 1

2) 23) 6

3.1) 73.2) 123.3) 19

2 27


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1

1.

1.1 ( 2 2545)

(PCU)

1.2

(- )

1.3

(Primary care) (Continuity) (Integrated) (Holistic)

1.4 (Four Principles of Family Medicine inCanada)

- (Patient-Doctor Relationship)

- (Skillful Clinician)- (Community-Based Practice)


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2

- (Resource Person to aDefined Population)

2. 2.1 (Small and Poly-

valent Team) Care Coordi-nator

2.2 1 10,000 80 (8 ) 1 1250 250-300

2.3 1

2.4 8

( ) ( ) 1 1


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3

1 8

1.

/

8.

2. /

3. a a a a

5.

7.

4.

6. /

6.1 .6.2


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4

1 8

1. - -

-

2. / - 1 2.1 Core Package

2.2 - Idea Expectation Concern

- 2.1 2.2 3.1-

3. - 3.1

2.2 4

3.2 -

3.3 -

3.4 -

3.5 -


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5

4. - (Group Counseling & Self Help Group)

5. - - Exit Care

(FU, Refer, Home Visit)

6. / - Care Coordinator Guidelines

7. - (CQI)

1 8. -

2.5 2.6

2.7 2 7- Re


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6

2 (7 Re)

1. Research

(Model Development)

2. Re-train

3. Re -think Re-Train

Empathic Relationship, Care Coordinator

4. Re-design ( ) (8 )

5. Re-tool ( Chronic chart Health maintenance card

)

6. Resource Management

7. Reassurance Health Care Accreditation

3.

1 2

Smalland Polyvalent Team()


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7

3

3.1 3.2 3.3

3.1

3 (Host) (Agent) (Environ-ment)

( ) 8 .

1

2 3

.

4 5

6.1 6.2 7

8


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8

8

1. - / ( ) 7 -

- ( )

2. / -

2.1 2.2 -

- Tourniquet test

3. -

3.1 ()3.2 - . Hematocrit 3.3 - . 5%D1/2NSS

4. -

()

5. -

- - (Follow Up)- -

-


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9

6. / - ( Tourniquet test positive Hct > 40% *)

- ( ) 24

8. - ( )

-

-

7. * . .

- 1


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10

8

1. -

2. / - 2.1 - (Treatment Card,

TB Register)

2.2 - 3 /

-

3. - 3.1 ( *)

- 3.2 - 3.3 - 3

-

4. - ( )

()

- (DOTS Watcher)


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12

3.2 a

a a a

a /

a

a

8 .

1

2 - ()

3

4

5

6.1 .

6.2

7 . Case Conference, , , (Continuous Quality Improvement)


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13

8


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14

8

1. - 40 -

2. / - 40 2.1

( )-

2.2 - .

-

3. - 3.1 ( *)

-

3.2 -

3.3 - 3.4 - .

- ( )

3.5 - . 50% Glucose


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15

4. - ()

-

5. -

- -

6. / - *

-

7. * .

- . Case Conference - (Continuous Quality

Improvement) Lab

8. -

-


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16

8 ( )

1. - 35 (

) () ()-

2. / - 2.1 - 2.2 -

. ( )-

3. 3.1 -

3.2 - PAP Smear ()

4. - 1 () ()

() () ()

-


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4. / - - -

5. -

- . Case Conference

6. -

-


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18

8

1. - () (

) () ()

2. / - 2.1 2.2 -

.

3. 3.1 -

3.2 - .

- -

1

4. - (Follow Up)-

5. / - . (EMS)

-

6. -


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19

7. - 1 -

(Safety Awareness)

-

-

- ( )

3.3

() ( )

8 .

1


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2 - ()

3 4

(Matrix Program)5

6.1

.

6.2

7 . Case Conference, , , (Continuous Quality Improvement)

8


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21

8

1. -

-

2. / - 2.1

- 2.2 -

.-

3. - 3.1 3.2 -

3.4 - .

4. -

()

5. -

-


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22

6. / - *-

7. * .

- . Case Conference

- 1

- (Continuous QualityImprovement)

8. -

-


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23

8

1. -

-

2. / - ( 2.1 ) 2.2 - (

) .-

3.

3.1 - 3.2 -

-

3.4 - .

4. - - - - - - -

()


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24

5. - - -

6. / - *

- ()

7. * .

- . Case Conference - (Continuous QualityImprovement)

8. -

-

-


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8

1. -

-

2. / - 2.1 - 2.2 -

. ( )

-

3. - 3.1 3.2 -

4. - ()

5. -

6. / - *

-


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26

7. * .

- . Case Conference - (Continuous QualityImprovement)

8. - -


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27

1 1 1

2 2 2 2

3 3 3

4 4

5 5 5 5

6 6 6 6

7 7

8 8 8 8

9 9 9


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28

1.

(...)//

, 1 - 3

, ,

, 1 - 3

, 1

, 1 - 3

, 1 , / ,

, , 1 , ,

, , , /

, 1 - 3

, 1 - 3 /


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29

(...)//

, 1 - 3

1 - 3

2.

(...)/

/

Pap test 1 3 3 35

3.

(...)//

/ , 1 - 3

/, , , 1 - 3

, 1 - 3 , , ,, , , , /


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30

(...)//

1 - 3

, 1 - 3 ,

, 1 - 3 , ,

, 1 - 3 , ,/

, 1 - 3 , ,,

, 1 - 3 , , , ,

> 20 1 - 3


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31

1.

(...)//

, 1 - 3 (, 3 , , )

,

20 - 40 3 > 40 1

, > 40 3 - 5

, > 40 1 - 3


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32

, 1 - 3 ,

, > 40 5

, > 45 3

(...) //

, > 35 3 - 5 ,,

, > 45 3 - 5 , HDL-C > 50 ,

, 3 - 5 ,

HIV ,

2.


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//

> 40

complete blood count ,

, > 40 /

,

T4, TSH

, /

HbsAg ,

VDRL ,

,


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//

, (Mass ScreeningChest X-ray Tuberculin test)

, ,

, < 40 /

,

tumor markers , (AFP), (CEA), (CA19-9), (CA125),

(PSA)

, ,

,


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35

1. , 2. , 3.

radioactive iodine

4. 5. , polyposis, ulcerative coli-tis, adenomatous polyp

6.

7.

8.

Hemoglobin / HematocritT4, TSH

Fasting plasma glucoseFecal occult blood, sigmoidoscopy colonoscopy

Tuberculin test cholesterol, triglyceride, HDL cholesterol

VDRL, Anti HIV

1. ,

2.

3. 40 - 49

4.

5. 40 6.

? - fetoproteinmammogram ()

Hb electrophoresis


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1. 12.

40

Insulin autoantibodies

1. 1. 2. 25 / 3. 4.

2. 1.

2. 3. 4. HDL-C 35 ./.5. Triglyceride > 250 ..6. IGT (impaired glucose tolerance) IFG (impaired fasting glucose)

3. 1. 2. 3. 4. 5. , , 6.

Documents

PCU Manual Intregated Care