出院患者随访率低的调查研究及对策

胡蓉　王晓燕　陈春花　彭晶

[摘要] 目的 探討出院患者随访率较低的原因，为制定相应的对策提供依据。 方法 对我院2018年全年出院患者的随访状况进行统计，分析出院患者随访率低的问题。并选取2018年和2019年第四季度全院22个科室的出院患者数和有效随访数，进行同期对比。 结果 2018年随访出现问题患者有23 906例，占全部随访人员的74.66%;有效随访例数为7804例，占全部随访人员24.37%。2019年随访出现问题患者有18 914例，占全部随访人员54.56%;有效随访例数为15 452例，占全部随访人员44.57%。2018年四季度出院患者随访率为27.5%，2019年四季度出院患者随访率为76.6%。 结论 出院患者随访过程中的主要问题包括人工登记电话号码错误、医务人员工作繁忙、病历提交至病案室后无法查询患者信息、医务人员工作量大积极性不高、没有创建信息化随访系统等。应使用互联网扩大随访影响，创建随访信息平台，并且医护结合，实现医护一体化随访，同时医院制定奖励机制，将随访工作纳入科室常规工作，以提高出院患者的有效随访率。

[关键词] 出院患者;随访率;互联网;随访系统

[中图分类号] R47          [文献标识码] B          [文章编号] 1673-9701（2021）04-0146-04

Investigation on the low follow-up rate of discharged patients and countermeasures

HU Rong1   WANG Xiaoyan2   CHEN Chunhua3   PENG Jing2

1.Derelopment Services， Ji′an Central People′s Hospital of Jiangxi Province， Ji′an   343000， China; 2.Department of Medicine， Jinggangshan University， Ji′an   343009， China; 3.Department of Nursing， Ji′an Central People′s Hospital of Jiangxi Province， Ji′an   343000

[Abstract] Objective To explore the reasons for the low follow-up rate of discharged patients and provide basis for formulating corresponding countermeasures. Methods The data on follow-up of discharged patients in our hospital in 2018 was collected to statistically analyze the low follow-up rate of discharged patients. The number of discharged patients and effective follow-ups of all 22 departments of the hospital in the four quarters of 2018 and 2019 were selected and compared in the same period of two years. Results In 2018， the number of patients with problems in the follow-up were 23 906， accounting for 74.66% of all the patients followed up; and the number of effective follow-up patients was 7804， accounting for 24.37% of all the patients followed up. In 2019， the number of patients with problems in the follow-up were 18 914， accounting for 54.56% of all the patients followed up; the number of effective follow-up patients was 15 452， accounting for 44.57% of all the patients followed up. Follow-up rate of discharged patients in the fourth quarter of 2018 was 27.5%， and that in 2019 was 76.6%. Conclusion The main problems in the follow-up process of discharged patients include wrong telephone number of manual registration， busy work of medical staff， inability to query patient information after the medical record is submitted to the medical record room， low enthusiasm of medical staff for heavy workload， and lack of establishment of an information follow-up system. The internet should be used to expand the impact of follow-up and create follow-up information platform， and the nurse-physician collaboration mode should be applied to realize the integrated follow-up. Meanwhile， the hospital should formulate incentive mechanism to include follow-up work into routine work of departments， so as to improve the effective follow-up rate of discharged patients.

[Key words] Discharged patients; Follow-up rate; Internet; Follow-up system

随访也称之为随诊，是医院根据医疗、科研、教学的需要，对诊治后患者的疾病疗效、发展状况继续追踪观察，将医疗服务延伸至院外。2012年《中国护理事业发展规划纲要（2011年-2015年）》提出延续性护理是“十二五”時期的重点任务，且随访干预是延续性护理的主要模式[1]。为实现“健康中国2030”规划和“十三五”期间的大健康、大卫生、大医学的医疗健康事业，已将慢性疾病管理置于首要位置[2]，慢性疾病患者的随访工作不容忽视，因此，临床随访工作尤为重要。……