Abstract:

Objective Based on the family medical platform（referred to as the platform）,a continuity nursing model for discharged patients was constructed and its application effects were evaluated in order to improve the quality of home care. Methods The platform include monitor platform and operation platform. Operation platform included：patient APP,providing service items and personal information pages,supporting user registration,project selection,service reservation and evaluation;nurse APP,providing service items,service application display,security center and personal information pages,supporting nurse registration,order receiving and security monitoring;and monitoring platform,responsible for the management of uses,service item maintenance,data management and safety monitoring. The platform was used to implement home care services for discharged patients. Data from October 2018 to March 2019 were collected including patients’ satisfaction and health knowledge mastery rate of patients to evaluate the platform. Results A total of 231 nurses and 109 patients were registered on the platform,164 times of home care and 8 times of accompanying visits were completed. The patients’ satisfaction rate was 93.9%,which was significantly higher than 86.2% of patients at discharge（χ ²=4.623,P=0.032）. Patients’ mastery rate of health knowledge was 97.7%,which was significantly higher than 87.6% of inpatients’ health knowledge（χ ²=14.545,P<0.001）. No complaints and adverse events occurred. Conclusion Constructing a family medical platform for continuity nursing has brought into the professional value of clinical nurses,provided systematic,standardized,safe and high-quality home nursing services for discharged patients,significantly improved the satisfaction of patients at home and the mastery rate of health knowledge,and provided an efficient and convenient way for patients to seek medical treatment.

Key words: Continuous Nursing, Family Medical Platform, Home Care, Informatization Platform, Rehabilitation Nursing

摘要：

目的 基于家庭医护信息化管理平台（以下简称平台）,构建居家延续性护理模式,并评价其应用效果,以期提高出院患者居家护理质量。 方法 平台由监控平台和操作平台构成。操作平台包括：①患者端APP,包括服务项目页面和个人信息页面,支持用户注册、项目选择、项目预约和评价;②护士端APP,包括提供服务项目、服务申请显示、安全中心及个人信息页面,支持护士注册、接单和安全监控。监控平台负责用户管理、服务项目维护、数据管理及安全监控。利用平台实施出院后患者居家护理服务。调取2018年10月—2019年3月患者满意度和健康知识掌握率等数据,评价平台效果。结果 共231名护士、109例患者完成注册,进行居家护理164次,陪诊8次;接受延续性护理服务后,患者满意度为93.9%,明显高于出院时患者86.2%的满意度（χ ²=4.623,P=0.032）;接受延续性护理服务后,患者对健康知识掌握率为97.7%,明显高于住院患者87.6%的健康知识掌握率（χ ²=14.545,P<0.001）,无投诉和不良事件发生。 结论 家庭医护信息化管理平台可充分发挥临床护士的专业价值,为出院患者提供系统、规范、安全、优质的居家护理服务,明显提高了居家患者满意度和健康知识掌握率,为患者提供了高效、便捷的就医途径。

关键词: 延续性护理, 家庭医护, 居家护理, 信息化平台, 康复护理