What is the management content of chronic diseases?

Chronic disease management system 1, set up full-time (part-time) staff to manage chronic diseases, establish a chronic disease prevention and control network in the jurisdiction, and make a work plan. 2. Regularly screen high-risk groups and key chronic diseases in the jurisdiction, grasp the epidemic situation of chronic diseases, and establish information files. 3. Classified monitoring, registration, filing and regular sampling survey of key chronic diseases in the population to understand the occurrence and development trend of chronic diseases. 4. Carry out health consultation and risk factor intervention activities for different groups of people, hold lectures on the prevention and treatment of chronic diseases, and distribute publicity materials. 5. Control and manage the patients with three chronic diseases (hypertension, diabetes and chronic respiratory diseases) that have been diagnosed within the jurisdiction. Establish health records for patients with chronic diseases, implement standardized management, follow up and make detailed records. 6. Establish a relatively stable doctor-patient relationship and responsibilities to ensure continuous service for patients with chronic diseases. 7, rural doctors and clinic doctors found all kinds of chronic diseases, timely report to the public health group, if there is any omission, false, once verified, will be dealt with seriously.