我国89家二级和三级综合医院出院患者随访服务现状调查  

Status of follow-up service of discharged patients from 89 Class Ⅱ or Class Ⅲ comprehensive hospitals in China

作　　者：陈静娟[1] 吴茜[1] 吴海霞 牛淑珍 施雁[1] Chen Jingjuan;Wu Qian;Wu Haixia;Niu Shuzhen;Shi Yan(Gastrointestinal Surgery, Tenth People's Hospital of Tongji University, Shanghai 200072, China)

机构地区：[1]同济大学附属第十人民医院胃肠外科,上海200072

出　　处：《中华现代护理杂志》2019年第13期1650-1654,共5页Chinese Journal of Modern Nursing

基　　金：国家自然科学基金青年项目(71704135).

摘　　要：目的调查我国二、三级医院出院患者随访服务的现状。方法采用便利抽样法,于2018年6月选取全国17个省、直辖市、自治区的89家二、三级医院的150个临床科室和228名临床护士,采用自制问卷调查科室出院患者随访的方式、内容、现存问题和建议。结果临床上主要由护理人员进行出院患者的随访服务,包括病房责任护士和专职护士,大多医院主要以电话随访为主,内容偏向于疾病健康教育和疾病咨询;出院患者随访服务在临床上存在的主要问题为“随访表单过于简单,缺乏专科特点”“随访形式比较单一,随访效果不理想”“人力资源限制,缺乏专门的随访人员”“随访结果缺乏汇总和分析”“随访中出现的护理问题缺乏跟踪和评价”。临床护士建议“随访数据应定期汇总和反馈”“增设出院病人随访中心统一管理”“随访表单应体现专科化特点”“应开展多学科团队合作”。结论出院患者随访服务对提高患者出院后的康复及生命质量具有重要意义,临床上的出院随访服务系统还存在诸多问题,建议完善适用于各专科的常见出院随访表单,构建多学科支持平台,推动随访管理系统科学化、信息化。Objective To investigate the status of follow-up service of discharged patients from Class Ⅱ or Class Ⅲ comprehensive hospitals in China. Methods In June 2018, we selected 150 clinical departments and 228 nurses of 89 Class Ⅱ or Class Ⅲ comprehensive hospitals in 17 provinces, Municipality and autonomous regions by convenience sampling. The self-designed questionnaire was used to investigate the ways, contents, existing problems and suggestions of follow-up of discharged patients. Results Follow-up service was mainly carried out by nurses including ward primary nurses and full-time nurses. Besides, the followup was mainly with the telephone follow-up, and its content tended to disease health education and consultation. The main existing problems of discharged patients in follow-up service were "follow-up form was too simple and lacking specialty characteristics","follow-up way was single and follow-up effects were unsatisfactory","human resources limits and lack of special follow-up staff',"follow-up effects lacking aggregate and analysis" and "nursing problems existing in follow-up lacking following and evaluation". Nurses suggested that "aggregate as well as feedback of follow-up data should be done regularly","increase follow-up center unified management for discharged patients","follow-up form should reflect specialty characteristics" and "develop multidisciplinary teamwork". Conclusions Follow-up service has great significance for improving rehabilitation and quality of life among discharged patients. There are a lot of problems in follow-up service system for discharged patients. We should perfect the common discharged follow-up forms applied to specialties, construct multidisciplinary support platforms and make follow-up management system scientific and informative.

关 键 词：护理 随访 出院患者 现状调查 

分 类 号：R47[医药卫生—护理学]