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Patients discharged from hospital are followed up through telephone, message, letter, email, visit and other ways, to investigate effectiveness of treatment, change of status, condition of rehabilitation, psychological state and so on. It is an important part of medical work. It is an open and extended form of medical service with the transformation of the medical model. It is one of the means to extend the medical service to the patients’ family.

So far, we offer two types of follow-up services: Aid and direct doctors or other health providers to improve and perfect follow-up questionnaires; Finish the complete follow-up questionnaires by our own researchers.


1. Objective

1.1 To knowledge the rehabilitation, psychological status and needs of discharged patients, to give timely and accurate health guidance or on-site nursing care, to improve the self-care ability and life quality of patients, and to promote the physical and mental recovery of patients.

1.2 To shorten the time of hospitalization, reduce the frequency of hospitalization, decrease medical costs, and optimize medical resources.

1.3 To understand the patients' opinions and suggestions on medical care and hospital management, to continuously improve the quality of medical and nursing care, to promote the satisfaction of patients, and to build a harmonious relationship between doctors and patients.


2. Management system of follow-up for discharged patients

2.1 Follow-up time:

Usually from the second day after discharge to two weeks, according to the circumstances of single or regular follow-up.

2.2 Follow up methods:

There are telephone, short message interaction system, WeChat group, home visits and other forms. One or more follow-up ways are chosen according to the patient's condition and needs. Standard follow-up language, access content and procedures are important components.

2.3 Follow-up questionnaire:

Medical personnel's service attitude, technical operation level, medical ethics, medical price, health environment, logistic service, patients' opinions and suggestions, etc.

The information about patients’ rehabilitation status, diet and activities is collected and grouped according to different kinds of diseases and treatments.

Establish follow-up registration, record the contents of follow-up, summarize patients' satisfaction, opinions and suggestions regularly, classify and feed back to the corresponding ward or department for improvement.


3. Follow up procedure for general discharged patients

3.1 The follow-up data were obtained.

After entering the HIS system and discharged patients information platform, and selecting the target group of patients in accordance with the follow-up, researchers enter the corresponding hospital work platform, check the follow up patient's disease record, doctor's order, hospital expenses to understand the hospital treatment and determine the key content of follow-up.

The data is registered by the responsible nurse after discharge. The contents include the general information of the patient, the diagnosis of discharge, the date of operation, the way of operation, the condition of treatment, contact phone number and supervisor doctor, etc.