护士主导健康体检检后随访闭环管理研究进展

Research Progress on Nurse-Led Closed-Loop Follow-Up Management after Health Examination

摘要: 健康体检是慢性病风险识别和疾病早期筛查的重要入口，检后随访质量直接影响异常结果处置、复查依从性和健康行为改变。护士在体检流程中与受检者接触频繁，具有健康教育、风险沟通、随访提醒、转诊协调和质量控制等优势，是检后随访闭环管理的重要参与者。本文检索健康体检护理服务、检后随访、信息化追踪、慢病风险干预和护士主导连续护理相关文献，综述护士主导健康体检检后随访闭环管理的内涵、运行框架、实施路径、评价指标及现实问题。现有研究提示，风险分层、个体化健康教育、电话或微信随访、信息化平台、多学科协作和持续质量改进有助于提升异常结果告知、复查转诊和健康管理参与效果。未来应进一步完善分层标准、岗位胜任力培养、信息安全管理和长期结局评价体系。

Abstract: Health examination is an important entry point for chronic disease risk identification and early disease screening. The quality of post-examination follow-up directly affects abnormal finding management, adherence to re-examination and health behavior modification. Nurses, who frequently interact with the examinees during the examination process, have professional advantages in health education, risk communication, follow-up reminders, referral coordination and quality control, and can play a key role in closed-loop follow-up management. This article searches for relevant literature on health examination nursing services, post-examination follow-up, information tracking, chronic disease risk intervention, and nurse-led continuous care, and summarizes the concept, operation framework, implementation pathways, evaluation indicators and practical challenges of nurse-led closed-loop follow-up management after health examination. Available evidence suggests that risk stratification, individualized health education, telephone or WeChat follow-up, information platforms, multidisciplinary collaboration and continuous quality improvement may improve notification of abnormal findings, re-examination and referral completion, and participation in health management. Future work should focus on standardized stratification criteria, position competency development, information security and long-term outcome evaluation system.