【摘要】 总结绍兴第二医院近年来对出院患者延续性护理模式的构建及实践经验。医院通过建立出院随访中心和“云随访”系统，成立延续护理小组，设置“互联网+”居家护理门诊，开设“互联网+护理咨询”线上门诊，成立慢性病院后疾病管理中心，开展健康教育讲座，建立医共体分院的网格化管理档案，规范延续护理的流程和制度等措施的落实，满足了当地患者延续性护理和治疗的需求，解决了出院患者的实际问题，大大提升了患者对医院的满意度。更多还原

【Abstract】 It summaried of Shaoxing second hospital in recent years to discharge patients continuity nursing mode construction and practice experience. By establishing discharge follow-up center and “cloud follow-up” system, the hospital set up a continuation nursing group and “Internet +” home care clinic, opened “Internet + nursing consultation” online clinic, established chronic hospital disease management center, health education lectures, and medical community branch grid management file, standardizing continuous nursing process and the implementation of the measures, met the needs of local patients continuity care and treatment, solved the practical problems of discharged patients, greatly improved the patients’ satisfaction with the hospital.更多还原