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目的探索新型家庭医生式服务团队中社区护士在慢性病健康管理中的作用。方法建立有序预约就诊模式,明确团队成员职责分工,制订新型社区护理慢性病服务流程,运用智能化慢性病管理平台为签约患者提供科学、连续的健康照护,为团队签约患者实施分层级和分类别的健康管理。结果 2013年1至10月和2014年1-10月比较,新增慢性病签约人数2221人,全科门诊诊疗人次新增10.68%,满意率提高了4.37%。社区面对面门诊随访人次新增203.94%,社区护士电话随访人次新增7.08%。结论社区卫生服务中心社区护士在慢性病健康管理中发挥了积极作用,规范了辖区慢性病患者管理,完善了居民健康档案。接受社区护士健康管理人数不断增加、患者满意度明显提升。
Objective To explore the role of community nurses in the health management of chronic diseases in the new family doctor service team. Methods To establish an orderly booking model for clinicians, clarify the division of responsibilities among team members, formulate a new chronic care service process for community-based care, use intelligent chronic disease management platform to provide scientific and continuous health care for contracted patients, and implement hierarchical and sub-categorization for contracted patients Health management. Results Compared with January-October 2013 and January-October 2014, the number of new contracted chronic diseases was 2221, the outpatient clinic attendance increased by 10.68% and the satisfaction rate increased by 4.37%. The number of face-to-face outpatient visits increased by 203.94% and that of community nurses by telephone was 7.08%. Conclusion Community nurses in community health service centers play an active role in the health management of chronic diseases, regulate the management of patients with chronic diseases and improve the residents’ health records. Accept the community health management of nurses continue to increase, patient satisfaction improved significantly.