目的:落实高血压、糖尿病等慢性病示范管理工作。方法:根据宁夏西吉县卫生局制订的高血压和糖尿病防治工作规范,结合苏堡乡卫生院的实际情况,有组织、有计划地分步实施,并收集整理相关资料。结果:高血压和糖尿病建卡建册分别为903人和16人,完成全年规范随访分别为837人和15人,管理率分别为92.69%和93.75%。经全程干预高血压控制良好和尚可590人(70.49%),糖尿病控制良好和尚可11人(73.33%)。家庭健康档案建档率达95.46%,社区健康教育与健康促进群众满意度和可信度大幅度提高。结论:乡镇卫生院开展慢性病规范管理,可加强慢性病有效控制,提高居民的健康保健和自我防病治病意识,促进社区和谐。 Objective: To implement the model management of chronic diseases such as hypertension and diabetes. Methods: According to the norms of prevention and treatment of hypertension and diabetes developed by the Health Bureau of Xiji County, Ningxia, combined with the actual situation of Supu Township Health Center, the implementation was organized and planned in a step-by-step manner, and relevant information was collected. Results: Hypertension and Diabetes card construction were 903 and 16, respectively, and completed the annual standard follow-up of 837 and 15 respectively, with management rates of 92.69% and 93.75% respectively. After a thorough intervention of hypertension control monk 590 (70.49%), diabetes well-controlled and still 11 (73.33%). Family health records filing rate of 95.46%, community health education and health promotion mass satisfaction and credibility greatly improved. Conclusion: The standardized management of chronic diseases in township hospitals can strengthen the effective control of chronic diseases, raise residents’ awareness of health care and prevention and cure of diseases, and promote community harmony.