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中文摘要：
目的：探索基于信息化慢病管理平台的社区脑卒中患者居家护理服务的方法和效果。方法：采用前瞻性研究方法，选取与方庄社区卫生服务中心签订家庭医生式服务协议的脑卒中患者作为研究对象。以电子档案中的资料作为基线数据，采用自行设计的调查问卷对研究对象基本资料、健康评估、居家护理需求进行调查。对居家护理访视干预开始时、干预后6个月、干预后12个月的患者疾病控制情况、生活自理能力、生存质量进行评估。同时将患者家庭访视评估情况录入慢病管理信息平台，给予连续的慢病规范管理。结果：运用信息化慢病管理平台实施脑卒中患者居家护理干预6个月、12个月后，患者自理能力和生存质量高于对照组，差异有统计学意义。结论：在信息化慢病管理模式下开展社区脑卒中患者居家护理服务工作，能够及时准确地掌握患者健康状况，实施连续性相关照护，规范脑卒中患者社区管理，提高患者自理能力和生存质量。
英文摘要：
Objective： To explore the method and effect of home nursing care for patients with cerebral apoplexy based on information technology management platform. Methods： A prospective study was used to study the stroke patients in the family physician service agreement with the community health service center in Fangzhuang. Take electronic file data as a baseline, the self-designed questionnaire was used to search the object of study basic information, health assessment, sick of home care needs investigation. 12 months after the intervention, the disease control, life and quality of life of the patients were evaluated by 6 months after the intervention. At the same time, the patient＇s family visit to the assessment of the situation into a chronic disease management information platform, to give a continuous chronic disease management. Results： In 6 months and 12 months after treatment, the patients＇ self-care ability index （Barthel） and quality of life （SIS） score were higher than those in control group, the difference was statistically significant. Conclusions： In the information chronic disease management service model of community stroke patients with home care service work, timely and accurate access to patient health status, the implementation of continuous： related care, standardized stroke patients with community management, improve the patient＇s self-care ability and quality of life.
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