T/BRACDCHE017-2025ICS11.020 CCSC05 团体标准 基层医疗卫生机构“三高”患者综合管理 指南 Guidelinesofcomprehensivemanagementforpatientswith"threehighs"inprimary healthcarefacilities 2025-10-27发布 2025-10-27实施 北京慢性病防治与健康教育研究会  发布 全国团体标准信息平台 T/BRACDCHE017-2025 I目次 前言.......................................................................................................................................................................Ⅲ 引言.......................................................................................................................................................................Ⅳ 1范围.....................................................................................................................................................................1 2规范性引用文件.................................................................................................................................................1 3术语和定义.........................................................................................................................................................1 4缩略语.................................................................................................................................................................1 5总则.....................................................................................................................................................................2 5.1以患者为中心.................................................................................................................................................2 5.2全程管理.........................................................................................................................................................2 5.3医防融合、综合管理.....................................................................................................................................2 5.4分级协作、互联互通.....................................................................................................................................2 6综合管理内容.....................................................................................................................................................2 6.1筛查与诊断.....................................................................................................................................................2 6.2首诊评估与健康档案.....................................................................................................................................3 6.3综合管理目标设定.........................................................................................................................................4 6.4分类管理.........................................................................................................................................................4 6.5健康教育与自我管理.....................................................................................................................................5 6.6生活方式干预.................................................................................................................................................5 6.7药物治疗.........................................................................................................................................................5 6.8家庭支持指导.................................................................................................................................................6 6.9随访管理.........................................................................................................................................................6 6.10转诊管理.......................................................................................................................................................6 6.11常见并发症管理...........................................................................................................................................7 7管理流程...............................................................................................................