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目的通过对辖区慢病患者进行电话随访,促进社区卫生服务中心的慢病管理工作,提高慢病患者的管理率和控制率。方法通过电话与慢性病患者或家属沟通交流,动态地收集慢病患者的信息资料,同时对慢性病人进行健康指导。结果通过电话随访可动态地收集辖区居民的慢病信息,同时对慢性病人进行健康指导,提高慢病患者的依从性和满意度,改善慢病患者生活质量,促进社区卫生服务中心的慢病管理工作。结论要想做好慢病电话随访工作,必须具备丰富的专业知识和娴熟的沟通交流及实际工作技巧。
Objective By telephone follow-up of patients with chronic diseases in the area, to promote chronic disease management in community health service centers and to improve the management rate and control rate of patients with chronic diseases. Methods Communicate with chronic patients or their families by telephone to dynamically collect the information of patients with chronic diseases and provide health guidance to chronic patients. Results By telephone follow-up, we can dynamically collect chronic disease information of residents in the area, provide health guidance to chronic patients, improve compliance and satisfaction of chronic disease patients, improve quality of life of patients with chronic diseases, and promote chronic disease management in community health centers jobs. Conclusion To do a good job in follow-up of chronic disease calls, you must have rich professional knowledge and skilled communication and practical skills.