住院病案首页智能化质量监控体系的设计与实施  

Design and Implementation of Intelligent Quality Control System for the Front Page of Inpatient Medical Records

作　　者：赵前前[1] 李丽华[1] 焦震宇[1] 刘力戈 李晓东[1] Zhao Qianqian;Li Lihua;Jiao Zhenyu;Liu Lige;Li Xiaodong(Beijing Chaoyang Hospital Affiliated to Capital Medical University,Beijing 100020,China)

机构地区：[1]首都医科大学附属北京朝阳医院,北京市100020

出　　处：《中国病案》2022年第8期3-5,共3页Chinese Medical Record

摘　　要：采用智能化病案内涵质控平台实现对全部住院病案首页实时智能化质量监控是促进医院高质量发展的有效助力工具。利用人工智能系统学习历史病案得到住院病案首页诊断与病案间关联的住院病案首页诊断推荐模型,实现多角色多环节的质量监控,既可在临床医师填写及编码员编码时,系统即时完成对住院病案首页内容的自动监控并实时进行提醒;又可在环节质控、终末质控中,智能化质控引擎实现自动按照规则监控。智能化质控规则引擎的应用,不但能全面覆盖全院所有病案,还能可视化展现病案的数据质量情况,为质控部门制定管理决策提供强力辅助,助力院级质控及绩效管理。智能化电子病历质量监控体系的建立提升了医院医疗质量,同时对科研分析、学科发展、医院精细化管理等提供数据基础。Using the intelligent medical record connotation quality control platform to realize the real-time intelligent quality control of all inpatient medical record front page is an effective power tool to promote the high quality development of the hospital. Using artificial intelligence system has been in hospital medical record home page study history record diagnostic and medical record association between hospital medical record front page recommendation model, realize the role more link quality control, as well as the clinicians when completed and coders coding, system on hospital medical record front page content of instant automatic monitoring and real-time remind;And in the link quality control, final quality control, intelligent quality control engine to achieve automatic monitoring in accordance with the rules. The application of intelligent quality control rule engine can not only comprehensively cover all medical records in the hospital, but also visually show the data quality of medical records,providing strong assistance for the quality control department to make management decisions, and assisting the hospital-level quality control and performance management. The establishment of intelligent electronic medical record quality monitoring system improves the quality of hospital medical treatment, and provides data basis for scientific research analysis, discipline development and hospital fine management.

关 键 词：人工智能 智能推荐 内涵质控 医疗质量 电子病历 

分 类 号：R197.323[医药卫生—卫生事业管理]