pcu manual intregated care
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:
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11000 0 2590 1637-8 0 2590 1631http://www.203.157.3.100 ()
1 : 2546
: 12,000
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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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17
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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20
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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25
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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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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34
//
, (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.
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