Abstract: Objective　To investigate the effect of the binding mode of "one patient,one doctor and one nurse" for chronic disease management in Beijing Fangzhuang.Methods　In 2014,Fangzhuang Community Health Service Center implemented the binding mode of "one patient,one doctor and one nurse" for chronic disease management.Using a systematic sampling method,we enrolled contracted residents who received treatment in Fangzhuang Community Health Service Center in October 2013 and October 2014,and conducted surveys on them by a self-designed questionnaire.The content of the questionnaire included general data,and residents’ satisfaction with outpatient visits,telephone follow-up,and lectures on health education.We distributed 200 questionnaires for two times,and collected 194 effective questionnaires with an effective rate of 97.00%.After a review of the databases of health records and hospital information system,we collected the person times of outpatient service and data of chronic disease management before and after the implemented the binding mode of "one patient，one doctor and one nurse".Results　There was significant difference in contracted residents’ satisfaction with the guidance during outpatient visits and the lectures on health education （P<0.05） and no significant difference in the satisfaction with telephone follow-up （P>0.05） before and after the implementation of the binding mode of "one patient，one doctor and one nurse".After the implementation of the binding model of "one patient，one doctor and one nurse",the increasing rates of the person times of outpatient service,the number of health records,the number of contracted residents with chronic diseases for each GP,the number of patients with hypertension under standard management,and patients with diabetes under standard management were 10.68%,17.29%,57.72%,22.10% and 70.91% respectively.Conclusion　The binding mode of "one patient,one doctor and one nurse" for chronic disease management has improved the number of residents and quality of standardized chronic disease management,reinforce the health records of residents,improve patients’ satisfaction degree,and bring innovation for the service mode of family doctors.

Key words: Family doctor service, Chronic disease, Disease managemnet, Community nurses

摘要： 目的　评价北京方庄医护“一对一”绑定式社区护士参与慢病健康管理模式的效果。方法　方庄社区卫生服务中心于2014年初推行了医护“一对一”绑定式社区护士参与慢病健康管理模式。采用系统抽样方法，抽取2013年10月、2014年10月前来方庄社区卫生服务中心就诊的签约居民为调查对象。2013年10月、2014年10月采用自行设计的调查问卷对签约居民进行调查，问卷主要内容包括签约居民的一般情况，签约居民对门诊访视指导、电话随访、健康教育讲座的满意度。两次均发放问卷200份，均回收有效问卷194份，有效回收率为97.00%。查阅计算机健康档案数据库和医院信息系统（HIS）数据库，收集医护“一对一”绑定式社区护士参与慢病健康管理模式实施前后的全科门诊诊疗人次数和慢病管理资料。结果　医护“一对一”绑定式社区护士参与慢病健康管理模式实施前后，签约居民对门诊访视指导、健康教育讲座的满意度间差异均有统计学意义（P<0.05），对电话随访的满意度间差异无统计学意义（P>0.05）。医护“一对一”绑定式社区护士参与慢病健康管理模式实施后较实施前全科门诊诊疗人次数、居民健康档案活档数量、家庭医生式服务签约慢病户数、高血压患者规范管理人数、糖尿病患者规范管理人数的增长率分别为10.68%、17.29%、57.72%、22.10%、70.91%。结论　医护“一对一”绑定式社区护士参与慢病健康管理模式提高了辖区慢病患者规范化管理的数量和质量，巩固和完善了居民健康档案，提升了患者满意度，创新了家庭医生式服务工作的模式。

关键词: 家庭医生式服务, 慢性病, 疾病管理, 社区护士