【摘要】 目的 构建基于互联网的医院-社区慢性伤口多学科联合居家护理服务模式，解决居家慢性伤口患者护理的难点。方法 构建医院-社区多学科联动慢性伤口居家护理云平台。患者在线申请，医院专科护士和社区护士分阶段整合多学科诊疗意见后联合实施居家伤口护理，社区护士负责后续的居家护理，平台定期随访。结果 实施6个月，为辖区内的137例患者提供线上咨询服务，其中8例接受了医院-社区联合居家护理服务，社区护士提供后续上门护理服务及随访36例次。结论 医院-社区多学科联动慢性伤口居家护理云平台整合了医院和社区服务中心资源，一定程度上解决了慢性伤口患者居家服务需求与服务供给矛盾。更多还原

【Abstract】 Objective To develop an Internet-based chronic wound care model by multi-disciplinary team in the hospital and community, and to solve the difficulties of wound care at home.Methods A cloud platform was developed for chronic wound care.Patients could use the platform for online appointment of the service, then specialty nurses of the hospital and community nurses collaborated to provide home wound care after integrating multidisciplinary diagnosis and treatment opinions.Community nurses offered follow-up home care, and regular follow-ups were also provided through the platform.Results During 6 months of application the platform, 137 patients used online consultation, of whom 8 received home care visits by the hospital-community team.The total number of follow-up home care visits and follow-ups provided by community nurses was 36.Conclusion The platform integrates the resources of hospital and community service center to provide home care service for patients with chronic wounds, and to a certain extent, solves the contradiction between home service demands and service supply.更多还原