智能化病历内涵质控平台设计及应用  

Design and Application of the Intelligent Medical Record Connotation Quality Control Platform

作　　者：林琳[1] 王韬[1] 邓超颖 LIN Lin;WANG Tao;DENG Chao-ying(Beijing Tiantan Hospital,Capital Medical University,Beijing 100050,P.R.C.)

机构地区：[1]首都医科大学附属北京天坛医院,北京市丰台区100050 [2]北京嘉和海森健康科技有限公司,北京市东城区100007

出　　处：《中国数字医学》2019年第11期48-50,112,共4页China Digital Medicine

摘　　要：目的:解决病历质控长期存在的低质低效、无法覆盖所有病历,且难以追踪管理等问题。方法:以大数据及人工智能方法,搭建一套可实时监测病历文书与患者病情变化是否一致的内涵质控规则库。结果:通过制定完善的质控规则,实现了在医生端、环节质控及终末质控对病历文书的自动监控、提醒及反馈功能,并通过可视化列表辅助完成质控管理,形成病历质量监管闭环。结论:智能化病历内涵质控平台的实施,不但扭转了以往病历核查的困境,显著提高了病历质量,同时也将为临床、科研及医院管理等提供重要支撑。Objective: To solve long-standing problems of low quality and low efficiency in medical record quality control, inability to cover all medical records, and difficulty in tracking and management. Methods: With big data and artificial intelligence methods, a connotation quality control rule database is built to monitor whether the medical records are consistent with the patient’s condition changes in real time. Results: By formulating the perfect quality control rules, the automatic monitoring, reminder and feedback functions of medical records at the doctor end and in link quality control and final quality control are realized, and the visual list is used to assist the quality control management, forming a closed loop of quality supervision of medical records. Conclusion: The implementation of the intelligent medical record connotation quality control platform not only solves the previous dilemma of medical record verification, but also significantly improves the quality of medical records, and provides important support for clinical, scientific research and hospital management.

关 键 词：大数据 人工智能 病历 内涵质控 机器学习 知识图谱 

分 类 号：R197.32[医药卫生—卫生事业管理] TP391[医药卫生—公共卫生与预防医学]