In order to promote the development of transitional care and provide high-quality transitional care for discharged patients,the transitional care department was established and the work mode,work contents and regulations were identified in September 2011. The full-time nurses in the department provided transitional care for discharged patients in the whole hospital by telephone follow-up,home visit,group meetings,telephone counseling and face-to-face counseling. The nursing department checked the workload in the transitional care department monthly. Within the six months,two full-time nurses provided guidance on mediation,rehabilitation exercises,catheter care and psychological care for 2820 discharged patients through telephone follow-up, carried out psychological rehabilitation group activities 24 times, received 1990 times of telephone counseling,and provided home visit services for 13 cases,referral services for 10 cases,and face-to-face counseling services for 253 cases. In addition,they reported the patients' concerns to the clinical departments for 95 cases,which promoted the continuous improvement of nursing quality in the clinical departments and increased patient satisfaction. The patients and hospital administrators highly appraised the transitional care,which further promoted high-quality nursing services.%为了更好地开展延续护理工作,推动本院延续护理的发展,为出院患者提供专业的延续护理服务.2011年9月设立了延续护理服务部,制订了一系列工作制度和管理方法,明确了延续护理服务部专职护理人员的隶属关系和工作内容.专职护理人员根据规定的工作量,对全院的出院患者实施延续护理工作,通过电话随访、心理康复小组活动、接受电话咨询和现场咨询、上门护理服务、双向转诊等方式实施延续护理服务.护理部每月核定其工作量的完成情况.实施半年来,共对2820例患者通过电话随访进行了用药、复诊、康复锻炼、管道护理和心理护理指导,开展心理康复治疗小组活动24次,接受来电咨询1190次,上门护理服务13次,双向转诊10次,现场咨询253次.此外,还向病区反映患者住院护理问题95个,病区根据问题进行持续质量改进,提高了住院患者的满意度.延续护理服务部的工作得到了医院和患者的肯定,进一步深化了优质护理服务.
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