建立以全科医生医疗团队为基础的双向转诊模式  

Establishment of Dual Referral Model Based on General Practitioner Team

作　　者：臧国尧[1] 方力争[1] 陈丽英[1] 朱文华[1] 戴红蕾[1] 陈建华[1] 卢崇蓉[1] 李利[1] 晁冠群[1] 张佳[1] 乔巧华[1] 黄丽娟[1] 施秀阳[1] 

机构地区：[1]浙江大学医学院附属邵逸夫医院全科医学科,浙江省杭州市310016

出　　处：《中国全科医学》2015年第29期3537-3539,共3页Chinese General Practice

基　　金：浙江省卫生厅项目(Y200921473)

摘　　要：目的建立以全科医生医疗团队为基础的双向转诊模式。方法浙江大学医学院附属邵逸夫医院医务部门专门召集全科医学科、门诊办公室、急诊科、信息中心、住院部等相关科室召开双向转诊会议,形成《医院与基层医疗卫生机构双向转诊制度》;明确了双向转诊原则和双向转诊上转、下转指证;确定了上转下转转诊单内容;签订了双向转诊协议书,明确双方责任;明确双向转诊流程。结果通过全科医生培训,使得上下各级医院全科医生密切合作,形成以全科医生医疗团队为基础的双向转诊模式代替既往以医疗行政部门为主导地位的双向转诊模式,使全科医生融入患者临床诊治全过程。2012年1月—2013年12月从社区卫生服务中心或县市级医院全科医生转诊而来的患者共计168例,男66例,女102例;年龄15~94岁,平均年龄56岁。经过门诊或住院检查评估与治疗,患者均明确诊断,并确定治疗方案或转专科治疗,病情稳定后出院,并转诊至原来的社区卫生服务中心或县市级医院全科医生继续进一步治疗管理。结论初步建立了综合医院与基层医疗卫生机构双向转诊制度和以全科医生医疗团队为基础的双向转诊模式。Objective To establish a dual referral model based on the general practitioner medical team. Methods A number of meetings of dual referral were convened by the Department of General Practice,Sir Run Run Shaw Hospital,School of Medicine, Zhejiang University, with the participation of department of general medicine, outpatient office, emergency department,IT department,inpatient department and other relevant departments. Through these meetings,the system of dual referral between hospitals and medical settings at primary level was settled,the principles of dual referral and the indications for upward referral and downward referral were determined,the content of dual referral letter was designed,the contract of dual referral was signed with the responsibilities of both parties clarified,and the process of dual referral was settled. Results By the training of general practitioners,doctors and hospitals of all levels cooperate closely,forming a dual referral model based on the general practitioner medical team in replace of the previous dual referral mode in which medical administrative department took the leading role and integrating general practitioners into the entire process of clinical diagnosis and treatment of patients. From January 2012 to December 2013,168 patients were referred from community health service centers or county-level hospitals by general practitioners,including 66 males and 102 females,with an age range of 15-94 and an average age of 56. Through outpatient and inpatient examinations and treatment, all the patients were definitely diagnosed and were treated with certain therapies or referred to specialized treatment, after which all patients kept stable condition, discharged and referred back to original community medical settings or county-level hospitals to receive further treatment and management by general practitioners. Conclusion The system of dual referral between comprehensive hospitals and medical settings at primary level and the dual referral mode based on general practitioner team we

关 键 词：病人转诊 全科医生 社区卫生服务 

分 类 号：R197[医药卫生—卫生事业管理]