延续性护理服务中心的设置与实践

The establishment and practice of transitional care center

为探索一套有效的延续性护理工作方法,我院于2012年9月成立了延续性护理服务中心,制定了一系列的工作制度和管理方法,设立专、兼职护理岗位,通过患者档案电子化管理、电话随访和温馨短信提示、上门专科服务、健康知识讲座、网络平台管理等方法实施延续性护理服务。延续性护理服务中心成立一年以来,建立延续性护理健康档案1200余份,电话随访3000余人次,开展健康知识讲座32次,上门专科护理服务120余人次。延续性护理中心的工作保证了患者康复的连续性,提高了患者的满意度和自我管理能力。

In order to establish an effective transitional care mode, the transitional care center was established in September 2012. Accordingly, a series of working systems and management practice were developed, full-time and part-time nursing positions were established, and electronic patient file management, telephone follow-up and warm SMS tips, home of specialist services, health lectures, and other methods were carried out to run extended care. Within one year, more than 1200 electronic patient files were built, over 3000 telephone cares follow-up for discharged patients and 32 times health lectures were carried out, and more than 120 cases received home visit services. The work of transitional care center ensured the continuity of patient rehabilitation, and improved patients＇ satisfaction and self-management skills.