Health management of tuberculosis patients
1、 Service object
Tuberculosis patients confirmed in the jurisdiction.
2、 Service content
（1） Screening and referral
For residents or patients coming to the hospital within the jurisdiction who have suspected symptoms of tuberculosis such as chronic cough, expectoration ≥ 2 weeks, hemoptysis, blood sputum, or fever, night sweat, chest pain or unexplained emaciation, fill in the "two-way referral form" on the basis of differential diagnosis. They are recommended to go to tuberculosis designated medical institutions for tuberculosis inspection. Conduct telephone follow-up within 1 week to see whether to go to see a doctor and urge him to see a doctor in time.
（2） First household visit
After receiving the notice from the superior professional organization to manage the tuberculosis patients, visit the patients within 72 hours. The specific contents are as follows: (1) Determine the supervisors, and the supervisors can be medical staff or family members. If family members are selected, they must be trained. At the same time, determine the place and time of medication with the patient. According to the chemotherapy plan, the supervisor shall be informed of the filling method, time and place of taking medicine of the patient's "tuberculosis patient treatment record card" or "multidrug resistant tuberculosis patient medication card", and the patient shall be reminded to take medicine and return to the hospital on time.
(2) Assess the living environment of the patients, and tell the patients and their families to do a good job of protection to prevent infection.
(3) Publicity and education on tuberculosis prevention and control knowledge were carried out for patients and their families.
(4) Tell the patient to see a doctor in time in case of aggravation, serious adverse reactions, complications and other abnormalities.
If no patient is seen in two visits within 72 hours, report the results of the visit to the superior professional organization.
（3） Supervise medication and follow-up management
1. Supervise medication
(1) Medical staff supervision: On the day of taking medicine, the medical staff will supervise the patient to take medicine directly.
(2) Supervision of family members: patients should take medicine in the presence of family members each time.
2. Follow-up evaluation
For patients supervised by medical staff, the medical staff shall record the follow-up evaluation results of patients at least once a month; For patients supervised by family members, primary medical and health institutions should follow up once every 10 days during the patient's intensification period or injection period, and once every 1 month during the continuous period or non-injection period.
(1) Assess whether there is a critical situation, if any, make an emergency referral, and actively follow up the referral within 2 weeks.
(2) For those who do not need emergency referral, understand the patient's medication (including whether the medication is regular and whether there are adverse reactions), and ask about the symptoms from the last follow-up to this follow-up. Ask about other diseases, medication history and lifestyle.
3. Classification intervention
(1) For patients who can take medicine on time and have no adverse reactions, continue to supervise the medication and make an appointment for the next follow-up.
(2) If the patient does not take the medicine according to the doctor's order of the designated medical institution, the reason should be found out. If it is caused by adverse reactions, it shall be referred; For other reasons, health education should be strengthened for patients. If the patient missed taking medicine for more than 1 week or more, it should be reported to the superior professional organization in time.
(3) Patients with adverse drug reactions, complications or complications should be referred immediately and followed up within 2 weeks.
(4) Remind and urge the patient to go to the designated medical institution for further consultation on time.
（4） Closing evaluation
After the patient stops the anti-tuberculosis treatment, the case should be evaluated, including: recording the time and reason for the patient to stop treatment; Evaluate the whole process of drug administration; Collect and report the "TB patient treatment record card" or "MDR-TB patient medication card" of patients. At the same time, the patient was transferred to the designated tuberculosis medical institution for treatment outcome assessment, and telephone follow-up was conducted within 2 weeks to see whether to go to the hospital and the diagnosis results.
