目的：充分发挥国家临床重点专科人才优势和技术力量，满足出院患者专业化健康教育需求。方法建立院科两级随访体系，院科上下联动，与基层社区医院互动，围绕患者康复及提高生存质量进行专业化健康教育，直接或间接满足患者康复需求。结果自院科两级随访体系构建以来，截至2014年12月1日共有效随访患者202630例次，帮扶培训基层社区工作人员20672例次，2013、2014年重庆市卫计委委托第三方调查的出院患者满意度中，我院满意度为89%、91%，连续2年蝉联第一。结论院科两级随访体系拓展了护士服务领域，既满足了出院患者的康复需求，又满足了基层医院的人才建设需要，有效发挥了重点专科护士的专业化健康教育作用。%Objective To bring the advantages of talents and technical forces of national clinical key specialty into full play and to meet the requirements of discharged patients for professional health education. Methods A follow-up system at hospital and department level was established then the linkage between the hospital and community hospital was developed. Professional health education focusing on improving the survival quality and rehabilitation of patients was implemented by nurses. Results A total of 202,630 patients were effectively followed-up since December 2013 and 20 672 grassroots-level community staff were assisted and trained. Patients’ satisfaction degree reached 89% and 91% in 2013 and 2014 respectively, which topped the hospitals in the survey conducted by Chongqing health development planning commission. Conclusion The follow-up system at hospital and department level can expand nursing services and effectively play the key role of professional nursing in health education which can not only meet the health needs of discharged patient but also the needs of talent construction of grassroots-level hospitals.
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