方法每一位病人出院后都建立病人小档案，在出院后的1周、1个月、3个月及半年内进行电话随访或者上门随访。
Methods the document of every discharged patient was established, then we call on or visit them one week, 1 month, 3 months and half a year after he is out of hospital.
并建立个人健康档案，定期监测血压、血糖，进行跟踪随访管理。
Health record was also established by testing blood pressure and blood glucose in follow up survey.
这是国内医院尝试通过信息技术平台建立出院病人随访健康档案和医生指导的新模式。
Thisis a new model for domestic hospitals to set up health file for patients through information technology platform and for doctor's guide.
这是国内医院尝试通过信息技术平台建立出院病人随访健康档案和医生指导的新模式。
Thisis a new model for domestic hospitals to set up health file for patients through information technology platform and for doctor's guide.
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