目的探讨规范性随访干预对社区高血压患者的服药行为改变的影响,方便社区医生开展高血压患者建档管理,建立长期随访干预模式。方法按照知情同意的原则,把2014-10~12参加本社区年度免费体检的确诊高血压患者964例纳入随访干预,按照2011年《国家基本公共卫生服务规范》建立高血压档案,每季度至少随访1次并记录高血压随访记录表,分析患者规律服药、间断服药和不服药的行为改变与定期随访干预的关联性。结果定期规范性随访干预对改变高血压患者服药行为有关联,并且延续性随访干预有利于提高患者服药依从性。结论定期规范性随访干预,能有效改变高血压患者服药行为,引导患者规律服药,提高服药的依从性。 Objective To investigate the impact of normative follow-up intervention on medication taking in community hypertensive patients, to facilitate community doctors to establish archives management of hypertensive patients and to establish a long-term follow-up intervention model. Methods According to the principle of informed consent, 964 confirmed hypertensive patients who took part in the annual free medical examination in this community from 2014 to December 12 were included in the follow-up intervention. According to the “National Basic Public Health Service Regulations” 2011, hypertension files were set up, at least every quarter 1 times and record high blood pressure follow-up record table, analysis of regular patient medication, intermittent medication and non-medication behavior changes associated with regular follow-up intervention. Results The regular normative follow-up intervention was associated with changing medication taking in hypertensive patients, and the continuous follow-up intervention was helpful to improve the medication adherence of patients. Conclusion Regular follow-up intervention can effectively change the medication behavior of hypertensive patients, guide the patients regularly taking medication, and improve compliance with medication.