Abstract: This paper introduced the construction and application of "Internet + Nursing Service" intelligent follow-up system for older adults with chronic diseases. The system included accurate follow-up needs assessment based on patient-reported outcomes, intelligent decision making engine supported by evidence-based knowledge base, and flexible and comprehensive online and offline follow-up services. The application of the intelligent system has brought benefits to patients, constructed a new follow-up practice model to meet the diversified and multi-level follow-up needs of older adults with chronic diseases, increased the enthusiasm of nursing staff, and provided a useful reference and enlightenment for the comprehensive development of "Internet + Nursing Service" in the future.

Key words: Internet + Nursing Service; chronic diseases of the elderly; follow-up; patient-reported outcomes; intelligent decision making