糖尿病患者管理模式的探索

目的 探索糖尿病患者管理的新模式。方法 建立糖尿病患者门诊诊疗新流程、标准化的诊疗常规及随访计划并建立患者临床电子病例系统,开展以启发患者“自我管理”为主的长期糖尿病教育等。结果 门诊服务质量明显提高,建成了10020例的糖尿病患者临床资料库及2563份血清标本库和DNA库,建成了一整套较为完整的糖尿病管理模式,奠定了临床和科研工作的基础。结论 对患者进行长期教育是糖尿病管理的基础和重要组成部分;应用计算机系统实行标准化信息管理是糖尿病管理的有效手段;制定统一规范的诊疗及随访方案是推进糖尿病良好管理的必由之路;不断提高医护人员专业素质是糖尿病管理得以最终被贯彻的保证;临床与科研相结合,是推动糖尿病管理向更科学的方向发展的动力。

Exploring of the Diabetes Care Model

Objective To explore the new diabetes care model. Methods A new flow for diabetic outpatient to visit the doctor, a uniform system for diagnosis,treatment and follow-up,an electronic medical record system,and a long-term diabetes education which mainly delighted patients on "diabetic self-management" were established.(Results)The service quality from the medical staff were improved markedly.Database including the clinical data of 10 020 patients and 2 563 serum samples and DNA samples were built up.A set of diabetes care model that laid the foundation for clinical and research work was formed. Conclusion Long-term education for patients with diabetes mellitus constitues the basic and important part of diabetic care model.The application of computer in diabetic care is the effective means.It is necessary to establish a uniform scheme for diagnosis,treatment and follow-up for the patients,and the improvement of medical staff's professional making ensures the successful implementation of the model.The combination of clinical practice and research work propels the development of scientific management model for patients with diabetes mellitus.