The system upgrades traditional manual telephone or paper-based follow-ups to a standardized, traceable, and efficient digital management model through structured data collection, automated follow-up processes (such as preset cycles by disease type, intelligent reminders, and multi-channel reach), and centralized data dashboards. It can significantly improve patient follow-up coverage and compliance, reduce the rate of lost to follow-up; provide continuous and standardized data support for clinical efficacy evaluation, rehabilitation program optimization, and real-world research; and support automatic early warning of abnormal indicators to assist medical teams in timely intervention, ultimately improving patients' long-term health outcomes and enhancing hospital research and quality management levels.