个性化临床科研随访闭环管理

摘要

In combination of the practice of the hospital, this paper made a research on the personalized follow-up template and scoring mechanism which could be customized according to the type of diseases and meet the clinical needs and researchers’ needs, so as to realize customized follow-up rules and plans. The follow-up of discharged patients was performed in group and then regularly according to the plan. The follow-up results could be used for scientiifc research and scoring, and eventually for health interventions and readmission proposal for the patients. The closed-loop management of the patients’ followed-up was realized, which not only accomplished the intentions of clinical follow-up for disease tracking and rehabilitation guidance, but also met the demands of scientiifc research staff for statistics of research cases.%本文结合我院实践，研究基于病种定制满足临床和科研人员需求的个性化随访模板与评分机制，自由设定随访规则和随访计划。出院患者入组随访，然后按计划定期执行随访，随访结果用以辅助科研和评分，最后根据评估结果对患者进行健康指导和再次入院治疗的干预，以此实现对出院患者随访的闭环管理，既满足了医生对出院患者进行病情追踪和康复指导的临床随访初衷，也实现了科研人员对科研病例的数据统计诉求。