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中国科技核心期刊（中国科技论文统计源期刊）
中国科学引文数据库（CSCD）核心库期刊
《中文核心期刊要目总览》核心期刊

中国护理管理 ›› 2023, Vol. 23 ›› Issue (2): 166-170.doi: 10.3969/j.issn.1672-1756.2023.02.002

• 特别策划·老年护理服务 • 上一篇    下一篇

“互联网＋护理服务”老年慢性病智能随访系统的构建及应用

盛芝仁 柳春波 郭晓莉 徐波雷 宋晓萍 袁长蓉   

  1. 宁波大学医学院附属医院党政综合办公室，315020 浙江省宁波市（盛芝仁，柳春波）；护理部（郭晓莉）；信息与数据中心（徐波雷）；健康管理中心（宋晓萍）；复旦大学护理学院（袁长蓉）
  • 出版日期:2023-02-15 发布日期:2023-02-15
  • 通讯作者: 袁长蓉，博士，教授，E-mail:yuancr@fudan.edu.cn
  • 作者简介:盛芝仁，本科，教授
  • 基金资助:
    宁波市“科技创新2025”重大专项（2019B10035）

Construction and application of the "Internet + Nursing Service" intelligent follow-up system for older adults with chronic diseases

SHENG Zhiren, LIU Chunbo, GUO Xiaoli, XU Bolei, SONG Xiaoping, YUAN Changrong   

  1. General Party and Government Office, The Affiliated Hospital of Medical School, Ningbo University, Ningbo, Zhejiang province, 315020, China
  • Online:2023-02-15 Published:2023-02-15
  • Contact: E-mail:yuancr@fudan.edu.cn

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摘要： 介绍了“互联网＋护理服务”老年慢性病智能随访系统的总体设计思路和具体实施方法，包括基于疾病生理变化客观指标及患者自我报告主观感受等多维数据实现随访需求的精准评估和诊断、循证知识库支撑的随访智能决策、以护士为主导的线上与线下相结合的随访服务。该智能系统的应用构建了满足老年慢性病患者多样化、多层次随访需求的随访模式，调动了护士的积极性，为未来全面开展“互联网＋护理服务”提供了有益借鉴和启示。

关键词: 互联网＋护理服务；老年慢性病；随访；患者报告结局；智能决策

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

中图分类号:  R47；R197
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