目的 探讨影响糖尿病离院患者医嘱依从性的相关因素及解决对策。方法 选取门诊初诊及住院好转离院患者189例作为观察对象，采用问卷调查法分别于出院后3、6、9、12个月进行随访，并在离院后的第7～12个月实施积极干预。结果 离院后6个月时糖尿病相关知识认知，饮食、运动、服药、定期检测等各项依从性指标低于3个月时的问卷结果，血糖控制率仅为25.4%。通过6个月跟踪护理干预有效提高了离院糖尿病患者医嘱依从性，血糖控制率达81.5%。结论 对糖尿病离院患者进行定期随访、健康管理密切了护患关系，强化遵医行为，达到血糖的有效控制。

Objective To study factors related to diabetes patients’ compliance with doctors’ instructions and solutions. Methods 189 patients with diabetes mellitus on their first visit or under recovery after leaving hospital were recruited, followed up for 3,6,9,12 months after by questionnaires. Active intervention was implemented between the seventh and twelfth month. Results The awareness of diabetes mellitus and submission indexes in diet, physical exercise, medication and regular examinations 6 months after discharge was lower than at 3 months, and the rate of blood sugar control was only 25.4%. By contrast, six months of follow-up nursing intervenetion enhanced dramatically patients’ compliance with doctors’ instructions, and the rate of blood sugar control was up to 81.5%. Conclusion Regular follow-up health management of patients with diabetes mellitus can lead to closer relations beteen patients and nurses as well as more effective control of blood sugar levels.