No abstract

Introduction: Among the main chronic diseases are cardiovascular diseases, with systemic arterial hypertension and diabetes mellitus as important risk factors. The identification of patients with high cardiovascular risk is a priority action in Primary Health Care. The Framingham score is used for this classification. The motivation for this study was the finding of the loss of outpatient follow-up of patients with hypertension and diabetes, which leads to treatment abandonment and a high number of complications. General objective: To implement a monitoring worksheet for hypertensive and diabetic patients in the family health strategy (FHS) and their classification according to Framingham score in low, medium and high risk. Methodology: Hypertensive and diabetic patients were located in the electronic medical record and classified according to the Framingham score using a spreadsheet with VBA computer language in the Microsoft Excel program. Results: A total of 219 medical records were analyzed from September to November 2021. Of the total, 210 users with systemic arterial hypertension (SAH) and 65 with diabetes mellitus (DM). Regarding cardiovascular risk, 86 patients (39.3%) fit into low risk, 37 patients (16.9%) in moderate/intermediate risk and the rest, 96 patients (43.8%) in high cardiovascular risk. Conclusion: The expected results with the organization of users with optimized spreadsheets bring improvements such as better control of four-monthly, six-monthly or annual follow-up according to the classification of cardiovascular risk, active search for absentees through community health agents with guidance on the importance of follow-up in PHC, community health indicators in relation to hypertensive and diabetic patients and targeting intervention proposals aimed at the population at higher risk such as lectures, physical activity groups and conversation circles on the subject. In addition, it is essential to note that there is a high number of consultations for this study group, and monitoring with nursing through its protocols is essential to contribute to improving health care.