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目的:探讨随访管理在慢性肾脏病(CKD)患者中的应用价值。方法:将中国人民解放军第一一三医院2013年8月~2015年8月诊断确诊为CKD的428例建档患者纳入随访管理,配备固定的随访专职人员,明确职责,科学管理随访资料,规范随访流程,制定随访计划,采取“金字塔”管理模式,分层随访。结果:2013年8月~2015年8月共建随访档案428例,随访总数376例,随访率达87.85%。结论:对CKD患者采取规范化随访管理,有利于控制疾病的发展。
Objective: To investigate the value of follow-up management in patients with chronic kidney disease (CKD). Methods: 428 patients diagnosed as CKD from August 2013 to August 2015 in Chinese People’s Liberation Army Hospital were enrolled in follow-up management, with a fixed follow-up full-time staff, a clear responsibility, scientific management of follow-up data, standardized Follow-up process, develop follow-up plan, to take “pyramid ” management model, stratified follow-up. Results: A total of 428 follow-up archives were completed between August 2013 and August 2015, with a total follow-up of 376 and a follow-up rate of 87.85%. Conclusion: Standardized follow-up management of patients with CKD is conducive to control the development of the disease.