病案首页智能控制系统设计及应用  

Design and Application of Intelligent Control System of Medical Record Home Page

作　　者：丁明明 蔡士轩 胡龙军 侯冷晨 钱明平[1] 张戟[1] 杨佳芳[1] 黄伟 史福娴 汪佳雯 牛培勤[4] 陈恳 陈跃军 DING Mingming;CAI Shixuan;HU Longjun(Shanghai Tenth People's Hospital,Shanghai,200072,China)

机构地区：[1]上海市第十人民医院,上海200072 [2]上海立信会计金融学院,上海201209 [3]上海森亿医疗科技有限公司,上海201203 [4]上海市第十人民医院病案统计室,上海200072

出　　处：《中国卫生质量管理》2021年第10期62-65,共4页Chinese Health Quality Management

基　　金：上海市申康医院发展中心临床管理优化项目(SHDC12019621);上海市卫计委智慧医疗专项课题(2018ZHYL0231)。

摘　　要：以自然语言处理、机器学习为核心的人工智能技术,可实现病案首页的智能填写。病案首页智能控制系统包含形式质控和内涵质控两大模块,拥有对病案首页的基本信息智能监测、诊断信息智能提示和预警、手术/操作信息智能推荐、编码员智能复核四大功能。应用后,在病案首页完成时间及内容的准确性、规范性、完整性方面,该系统相较于传统病案首页信息系统具有一定优势。病案首页智能控制系统可辅助医生和编码员快速、准确完成首页内容填写,有助于提高病案首页质量。The artificial intelligence technology with the core of natural language processing and machine learning realized the intelligence of filling in the home page of medical record.The intelligent control system for the home page of medical record included two modules:formal quality control and connotation quality control,which can realize four functions of intelligent monitoring of basic information,intelligent reminding and warning of diagnosis information,intelligent recommendation of surgery/operation information,and intelligent review of coders.After application,the system had certain advantages over the traditional medical record home page information system in terms of the completion time and the accuracy,standardization and completeness of the content.The intelligent control system of the home page of medical record can assist doctors and coders to complete the content of the home page quickly and accurately,and help improve the quality of the home page of medical record.

关 键 词：人工智能 病案首页 质量控制 智慧医院 质量与信息化 

分 类 号：R197.324[医药卫生—卫生事业管理]