摘要
目的探索慢性肾脏病（CKD）患者的随访管理方法，并进行效果评价。方法2011年8月成立CKD随访管理中心；合理进行人员配置，组建以肾科医生、肾脏专科护士和营养师为核心的随访团队，明确岗位职责；优化随访流程；开展多样化的健康指导及全面收集患者资料并存档。结果截止2012年11月底，CKD建档病例数共705例，回访率100％，门诊量：复诊10～30个／d，建档3～5个／d，健康教育2—3个／d。结论随访是提高患者疾病自我管理能力，预防和延缓CKD进展的有效途径。而规范的管理、合理的人员配置、优化的随访流程、全面的随访内容和多样化的健康教育是随访有效的重要保证。
Objective To investigate the management method of follow-up on patients with Chronic kidney disease（CKD） and to assess the effectiveness of the new approach. Methods A CKD follow-up management center has been established in the nephrology clinic in August, 2011. A follow-up team consisted of nephrologists, professional nurses and clinical nutritionists was set up. The responsibility of each post was clearly defined and the follow-up flow path has been optimized through clinical practice. Patients＇ medical records were collected in detail and put into files. Various heath education activities and courses were developed for patients in the center. Results Till the end of November,2012, a total of 705 patients were recruited into the center. The rate of return visit was 100%. There were averagely 10 - 30 patients per day for return visit,3 -5 newly included patients per day and 2 - 3 cases of health education performed everyday. Conclusion Follow-up is an effective way to enhance the patients＇ ability of self-management over diseases and to retard the progression of CKD. While normative management, rational personnel allocation, optimized follow-up process, comprehensive follow-up content and various health education are the key factors to ensure an effec- tive follow-up.
出处
《四川医学》
CAS
2014年第3期333-335,共3页
Sichuan Medical Journal
关键词
慢性肾脏病
随访管理
疾病自我管理
健康教育
chronic kidney disease
follow-up management
self-management over disease
healtheducation
