Abstract: Background　The prevention and control of chronic disease in China is in a severe situation,and chronic disease service at this stage is not optimistic.Objective　To understand service process of chronic disease,find out the existing problems,and provide basis for improving quality of community health services and relevant policies and measures set out by our government authorities.Methods　29 community health service centers in two urban areas of Guiyang downtown were investigated in October 2015,two centers did not cooperate with the investigation,and actually 27 were in the survey.Under qualitative research method,principals of 27 community health service centers and leaders of general practitioner team were interviewed deeply with self-made interview outline.Interview contents included service process and major service contents provided by general practitioner team for community chronic disease patients （including discovery of patients with chronic diseases,screening,follow-up,physical examination,management,treatment,usage of health records,etc.）.Results　Each community health service center in main urban area of Guiyang City had an average of 1 to 2 general practitioner teams,each team was responsible for basic public health services of about 1 500 residents who had signed health service agreements,200 to 300 of them were patients with chronic diseases.General practitioner team members undertook the work of residents’ outpatient service,chronic disease screening,finding and management.Chronic disease management team was mainly responsible for chronic disease management,and it was the branch of general practitioner team.44.4% （12/27） of chronic disease management teams were led by doctors,44.4% （12/27） led by nurses,11.2% （3/27） led by non-medical professionals.Non-clinical professionals such as community nurses were mainly responsible for follow-up of chronic diseases,putting forward lifestyle guidance,and general practitioners for proposing medication guidance.25.9% （7/27） of community health service centers set up specialized community chronic disease clinics,59.3% （16/27） did not and shared with the outpatient clinics of general practice,11.1% （3/27） depended on outpatient medical care of superior hospitals,and another 3.7% （1/27） did not provide clinical outpatient services.Health records in the service process of chronic disease were mainly used for recording follow-up and physical examination information.There were 4 kinds of cooperative ways of general practitioner team in the management process of patients with chronic disease:service principals of chronic outpatient,chronic disease management department,relying on medical services of superior hospitals and lacking of medical care.Conclusion　The chronic disease service processes of general practitioner team basically comply with requirements of national regulations,but phenomena such as the separation between basic medical care and basic public health services,imperfect teamwork mechanism,insufficient effectiveness of health guidance,and lacking of effective use of health records are still existed.

Key words: General practitioner team, Chronic disease, Service process, Community health services

摘要： 背景　我国慢性病防治形势严峻，现阶段社区慢性病服务情况不容乐观。目的　了解贵阳市主城区全科医生团队社区慢性病服务流程，并发现存在的问题，为提高社区卫生服务质量及政府主管部门制定相关政策措施提供依据。方法　于2015年10月，对贵阳市中心两城区的29家社区卫生服务中心进行调查，其中2家不配合调查，实际调查27家。采用定性研究的方法，以自编访谈提纲对27家社区卫生服务中心的主要负责人或全科医生团队长进行深入访谈。访谈内容包括全科医生团队对社区慢性病患者的服务流程及主要服务内容（包括慢性病患者的发现、筛查、随访、体检、管理、治疗、健康档案使用情况等）。结果　贵阳市主城区每家社区卫生服务中心平均有1～2个全科医生团队，每个团队负责约1 500例签约居民的基本公共卫生服务，其中有200～300例慢性病患者。全科医生团队成员承担着居民门诊、慢性病筛查与发现、慢性病管理等工作。其中慢性病管理主要由慢性病管理团队负责，该团队属于全科医生团队的分支。44.4%（12/27）的慢性病管理团队由医生领导，44.4%（12/27）由护士领导，11.2%（3/27）由非医学专业人员领导。慢性病随访主要是由社区护士等非临床专业人员负责，并提出生活方式指导，全科医生提出用药指导。25.9%（7/27）的社区卫生服务中心设置专门的社区慢性病门诊，59.3%（16/27）未设置专门的社区慢性病门诊而共用全科门诊，11.1%（3/27）依托上级医院的门诊医疗，另有3.7%（1/27）目前未提供临床门诊服务。慢性病服务过程中健康档案主要用于记录随访与健康体检的信息。全科医生团队在慢性病患者管理过程中存在4种协作方式，分别为以慢性病门诊为服务主体、以慢性病管理科为主体、依托上级医院的医疗服务以及缺乏医疗的协作方式。结论　全科医生团队的慢性病服务流程基本遵循国家规范要求，但存在基本医疗与基本公共卫生服务分隔、团队协作机制不健全、健康指导有效性不足、健康档案缺乏有效利用等现象。

关键词: 全科医生团队, 慢性病, 服务流程, 社区卫生服务